Falsifying Medical Records and Identifying Missing or Misleading Information

Falsifying medical records is no easy feat. Proving that it has occurred can be just as challenging. Patient medical records are legal documents with federal and state laws governing their management. Any appearance of medical record tampering or inappropriate altering can lead to investigations and can impact legal proceedings relying on records as evidence.

“Regardless of the venue or task at hand, the legal nurse consultant is perhaps the most cost-effective resource on your legal team.”

State law governs the process to make any alterations to patient records deemed necessary. Therefore, clinicians and facilities may face increased liability if these processes are not followed. Knowing that there are standard methods in place to responsibly document legitimate changes, juries are often suspicious of tampering claims. However, medical record falsification does still occur, and it is important to know how to identify record fraud red flags.

EHRs and Falsifying Medical Records

Records of medical care and events should be created in an accurate and timely manner while a patient is in a facility and completed at the time of discharge. Outpatient settings and physician offices also require accurate and timely records of patient care.

“Falsification and tampering come in many forms – removing a diagnostic report, inserting information without standard documentation, rewriting or destroying the record, omitting significant facts, or even creating records for nonexistent patients or staff.”

When appropriate modification occurs, original entries are never obliterated from medical documents. For handwritten entries, the original entry may contain a line through prior information and correction written beside it, identifying who corrected and when. Electronic health record (EHR) systems have procedures to document appropriate medical record changes. Unique to EHR is the audit trail. This is a record detailing each person who accesses the record system. It also notes when the system was accessed and what changes were made. All entries are easily identified electronically, including identifying the details of a change and who made it. This makes it more difficult to tamper with records. Most healthcare professionals are aware that forensic experts can analyze both physical and electronic records for tampering and determine the identity of the person making the suspicious entry. So, they are hesitant to risk inappropriate documentation changes.

But record falsification does happen in the healthcare community. Often it is an attempt at damage control for a known error, an adverse medical outcome, or a filed lawsuit. Falsification and tampering come in many forms. These can include removing a diagnostic report, inserting information without standard documentation, rewriting or destroying the record, omitting significant facts, or even creating records for nonexistent patients or staff.

Red Flags for Medical Record Falsification

Legal teams should know the potential for wrongdoing in certain circumstances – any medical catastrophe, surgical error, unexpected death, hospital-acquired condition, or unexpected facility event (a patient leaving without being discharged.) A patient’s legal representative requesting copies of medical records may be the first indication of a pending lawsuit. Consequently, records that are not produced promptly are a definite red flag.

How to spot red flags for medical record falsification in medical record review:

• Look for incomplete, sparse, or incredulous information about the event that resulted in harm.
• Note any conflict between the documentation and what the patient has said.
• Compare progress notes with imaging reports, lab reports, pharmacy data, etc.

If the result of the injury is not consistent with the documented record – or if the complaints of a patient suing the facility align too well with information that happens to be missing – a healthcare expert should be brought in.

Role of Legal Nurse Consultants in Identifying Falsified Records

Some fraudulent documentation entries are easier than others to identify. Nurses know precisely what standard information medical records should contain. They can quickly spot missing, inconsistent, or out-of-order data. This makes a legal nurse consultant (LNC) extremely valuable in cases with suspected medical record fraud.

LNCs work with medical, pharmacy, and employment records to create an accurate timeline and determine inconsistencies. They are in a unique position to analyze the information within the records and pinpoint what is missing and recommend items to obtain.  An LNC can interview potential new clients, screen a case for merit, and identify liability and deviation from the standard of care.  He or she can provide questions to ask in a deposition. Then, they can summarize the testimony given on the record – another opportunity to identify missing or misleading information. Regardless of the venue or task at hand, the legal nurse consultant is perhaps the most cost-effective key player on your legal team.

How Med Law Advisory Partners Can Help

For nearly two decades, Med Law Advisory Partners has provided national medical-legal consulting services across a variety of disciplines. Our highly qualified consultants provide the edge you need in case strategy, record review, health system improvement, and more. Get in touch with us today to schedule a conversation.

Founded by Alicia Davis, RN, LNCC, Med Law Advisory Partners (and former ALN Consulting) provides resources and expertise in the areas of safe opioid prescribing, medical malpractice, and post-acute care litigation, including COVID-19 claims. Alicia and her team have worked with government entities, healthcare systems, insurers, and senior-living operators for nearly 20 years, helping mitigate risk and manage medical-legal and healthcare fraud claims.

Originally published July 22, 2016. Last reviewed Feb. 27, 2021.