When Faced with a Medical Malpractice Claim, Never Alter Your Medical Records

When faced with a medical malpractice claim, a physician’s most important line of defense is the medical record of his or her interactions with the patient. A properly maintained medical record system can be the golden shield that proves the doctor followed best practice standards; a medical record altered post-claim can be the sword a physician falls on.

Spoliation is the legalese used to describe the alteration of a medical record after being informed of a possible medical malpractice claim. Spoliation of evidence occurs when a person destroys, hides, alters or withholds information that is important to a lawsuit. In many cases, a court will consider that when a physician has taken the time and effort to alter evidence, it is reasonable to conclude that there was a significant indicator of liability to hide.

Under no circumstance should a physician alter a medical record after being served with a claim. Nothing could be more disastrous to a defense against a medical malpractice claim than altering the medical record. Too often, a physician faced with an adverse patient outcome will try to revise history by altering or destroying records. Sometimes a doctor fearing a lawsuit may delete harmful facts or add new facts to the record. A good plaintiff’s attorney will discover the alteration, damaging the credibility of the physician and his or her testimony. If found guilty of negligence after having discovered the physician had retroactively altered medical records, a jury is likely to want to punish the doctor, awarding the highest monetary damages possible.

While a physician should never alter a medical record in response to a medical malpractice claim, it is even more tragic if the alteration is done to an electronic medical record. Electronic medical records are easy to investigate with the assistance of a computer expert, detailing the date and time new information was inserted or old information deleted.

Given the importance of the medical record in defending against a malpractice claim, it is vital for the physician to have the record available to defend proper care. The medical record’s value to the defense is destroyed if the plaintiff’s attorney is able to impugn the credibility of the record. In fact, in these circumstances, the medical record becomes a cudgel to beat your defense over the head with.