Page 34 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

coverage. Although insurers and risk managers constantly remind

physicians of this, we continue to see alterations sabotage our

efforts to defend medical malpractice lawsuits. Changes in the
medical record, including additional notes, after receipt of a claim

or lawsuit should not be made without consulting an SVMIC

claims attorney. No matter how great the temptation, altering a

medical record after an adverse outcome is rarely defensible and

often not even necessary. Attorneys would rather deal with a

flawed but intact medical record than a manufactured one.

Alteration of the medical record could trigger an allegation of

spoliation. The theory of spoliation of evidence refers to an

intentional destruction of evidence for purpose of depriving

opposing parties of its use. Spoliation may subject you to
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professional discipline, may be used as a separate grounds for a

claim independent of any alleged malpractice and may even result

in criminal charges.

There are times, in the normal course of treatment, when additions

or corrections to a medical record are acceptable, provided they

are made appropriately. To make a correction in a paper chart,
simply draw a single line through the original entry, make the

correction, then date and initial it. When making a lengthy

correction or an addition to the record, clearly mark it as an

addendum, enter it chronologically in the chart and date and sign

the entry. Always avoid writing in the margins or squeezing words
between lines, as this can give the appearance of an alteration

even if it is not. Any change to the chart should make it clear who

5 Desselle v. Jefferson Parish Hosp. Dist. No. 2, 887 So. 2d 524, 534 (La. App. 5th Cir. 2004)

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