Risk Management

Don’t Ever Alter Records in an Attempt to Change Facts

By Jerome W. Bettman Sr., MD

Argus, October, 1991

Altering records in an attempt to change the facts is one of the most certain ways to lose a malpractice suit. Never do it. It is dishonest, unethical and is nearly always detected. Once the plaintiff’s attorney is able to show that a physician has improperly changed a patient record, the attorney can maintain that nothing the physician says can be trusted and the defense will lose.

There is often a great temptation to alter records when a claim has been filed. For example, if an ophthalmologist has neglected to record the intraocular pressure in a patient on whom another ophthalmologist later makes the diagnosis of glaucoma with significant nerve damage, the defendant-ophthalmologist may be tempted to insert a pressure reading, especially if there is plenty of space on the record. The ophthalmologist may even consider using the same pen as was used for the rest of the record and make it correspond in all respects to what has been written before.

How Can These Careful Alterations Be Detected?

Records are frequently duplicated for insurance reports. If the plaintiff’s attorney obtains a copy of the record before it was altered and then receives a copy of the altered record, the defense loses. In addition to this hazard, there are companies whose business it is to detect such changes.

When is Making Changes in a Record Proper and How Should It Be Done?

When taking a history, the patient may change his or her story, or the ophthalmologist might be interrupted in his recording or thought process and write something that is irrelevant or wrong. These are instances when corrections may and should be made. The proper way to make such a correction is to draw a line through the unwanted statement in such a manner that it is still legible, write the appropriate statement, date and initial it. A plaintiff’s attorney cannot maintain that this method of change is an attempt to conceal the true facts and a defendant-ophthalmologist who handles corrections in this manner will be accepted as honest and his statements are more likely to be believed.

In conclusion, once a claim has been made, never, never alter the plaintiff’s record no matter how tempting or damning the document.