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Medical Records

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questions?

Junior Member
What is the name of your state? NC
Is there any way to contest the documentation in your medical records when you know or have reason to believe that the information has been altered after the accident occured?
 


ablessin

Member
questions? said:
What is the name of your state? NC
Is there any way to contest the documentation in your medical records when you know or have reason to believe that the information has been altered after the accident occured?


If a physician feels the need to make a correction to your records, an ammendment should be done, and should be dated, noted and initialed by the physician that it was an ammendment.
There should not be white out, erasers or anything like that in your chart.
 

questions?

Junior Member
ablessin said:
If a physician feels the need to make a correction to your records, an ammendment should be done, and should be dated, noted and initialed by the physician that it was an ammendment.
There should not be white out, erasers or anything like that in your chart.
What if it is that they did not document the information in the first place or completely rewrote the notes because they had the records for over a year before turning them over all the while knowing a suit was going to be filed or attempted to be filed?
 

ellencee

Senior Member
A handwriting expert can evaluate the records and testify if necessary. Obtaining that service will be expensive.

Text may be corrected legally with a single strike-through, signed and dated but not obstructing any word or symbol of the original text.

A legal entry may be made at a later date. If properly identified as a late entry, the entry is legal; however, the content of such an entry may be subject to scrutiny. Your attorney knows how to manage such entries (testimony) in medical records.

EC
 

purple2

Member
Most providers will allow patients to write their own note to be appended to the record, upon request. You can write that you disagree with the contents of the record, the reason, and any supporting facts. Most providers require this entry to be very brief.

I'm not sure doing so would affect your case, since you would already be testifying that you disagree with the provider's records. Ask your attorney.
 

ablessin

Member
questions? said:
What if it is that they did not document the information in the first place or completely rewrote the notes because they had the records for over a year before turning them over all the while knowing a suit was going to be filed or attempted to be filed?

re-writing a patients medical record would be very time consuming for the physician. However, the fact that it was all done at one sitting would be sort of obvious since the hand writing would all flow the same. An expert would be able to notate this occurance, however as EC mentioned, would be costly.

I find it hard to believe any physician would remember a visit from a year ago, thus the never documenting it seems far-fetched. I am not saying not possible, but I would imagine details would be fuzzy after a year ..........

Is this a private office records, or a hospital record?
 

PinHead

Member
if there are changes you should be aware of it

ablessin said:
If a physician feels the need to make a correction to your records, an ammendment should be done, and should be dated, noted and initialed by the physician that it was an ammendment.
There should not be white out, erasers or anything like that in your chart.
if there are changes you should be aware of it as well as what are the original information there, everything should be noted and dicumented to avoid doubt etc...
 

questions?

Junior Member
ablessin said:
re-writing a patients medical record would be very time consuming for the physician. However, the fact that it was all done at one sitting would be sort of obvious since the hand writing would all flow the same. An expert would be able to notate this occurance, however as EC mentioned, would be costly.

I find it hard to believe any physician would remember a visit from a year ago, thus the never documenting it seems far-fetched. I am not saying not possible, but I would imagine details would be fuzzy after a year ..........

Is this a private office records, or a hospital record?
This involves a university record regarding a discharge immediately afterwhich the patient attempted suicide in the manner they warned the Dr. and staff they would that resulted in catastrophic permanent diability.
 

barry1817

Senior Member
rewriting charts

In a case that I was involved with the office attempted to rewrite the records to improve their position.

the problem with doing that was that the chart became so different from all others in the office, which indicated the problems with the patient, and the attempts to justify what occurred.

By itself, a single chart may prove to be very difficult to show any alteration, but when compared with other charts, the differences in notes, documentation, narrative, show the problem.

With the new HIPAA regulations getting the records to show the differences might be more difficult, but could be accomplished by having all patient names and personal notations deleted.

It would then be pertinent to check the appropriate boards to see if any previous problems exist with this professional, and if there has been any legal case, it becomes important that those records be reviewed in regard to noting how the professional dealt with tose charts.

Not easy, but there are code sections about alteration of records with intent to deceive, and citing that part of the professional code, might be sufficient for a judge to allow those documents to become a part of any action you might consider.

[email protected]
 

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