| April 8, 2006
Don’t alter your records in a malpractice case.
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Don’t alter your records in a malpractice case AND don’t write false affidavits for another doctor in a malpractice case.
“Don’t alter your records in a malpractice case AND don’t write false affidavits for another doctor in a malpractice case. “
Wrong. The first one is illegal, the 2nd is a standard of practice.
One of my two brushes with the legal establishement while a physician involved a doctored chart.
The patient suffered a stroke at home 5 days postpartum that was likely due to her hypertension. Hypertension that was likely present prenatally, was treated throughout pregnancy as pregnancy induced hypertension in the usual maner with aldomet and her blood pressure returned to borderline elevated postpartum.
Once the stroke was known and the patient was admitted the attending anesthesiologist wrote a highly detailed note in the chart dated two days post partum about how we thoroughly checked her blood pressure and spoke with her by phone post partum day 2 indicating she felt well.
The thing is we did do these things as a matter of routine care, and I had specific recall of the phone conversation with the patient, a routine part of post-anesthesia care when patients are discharged so soon after a procedure that we cannot provide comprehensive followup while the patient is still at the hospital.
The problem was none of this was documented. So no big deal. The bigger problem was that the attending decided that it should be documented, Ok fine, but the gargantuan mistake was dating the note as if it were documented contemporaneous to the actual timing of the patient contact. The attending managed to make the effort so transparent it was almost painful for anyone to read. Though nothing wrong was done, the fear of litigation led this attending to create a paper trail that screamed of cover-up, even though there was nothing to cover. A medico-legal non-event became a slam dunk for the lawyers. Once one part of the chart is easily refuted as a fabrication then no one on the case can hope for honest and frank testamony to save their ass. The case settled for an an amount I can only guess at.
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