There are few things more devastating to a physician's right to practice medicine, or to the successful defense in a medical malpractice action, than the revelation that he has altered his medical records. In fact, in Florida the fraudulent alteration or destruction of a hospital record is a second degree misdemeanor and such activity with regard to any patient record is grounds for adverse action by the Department of Professional Regulation. It would seem then that with such laws and all the publicity surrounding the importance of the integrity of records, that this would no longer be a problem. However, in the supercharged atmosphere of medical malpractice claims, alteration still occurs with surprising frequency. It is not always done with an intent to defraud, but rather at times, with the hope that by recording correctly a prior error, a claim may be avoided. Regardless of the intent, a physician cannot expect, in the sophistication of today's litigation techniques, that alterations will go unnoticed. Both the plaintiff and defense bar have access to document examiners who can, with surprising accuracy, uncover the truth. In this regard, they are, able to review the types of ink utilized and draw conclusions as to whether the writing instruments were the same; analyze the writing itself to determine whether entries were made at or near the same time; analyze the paper to determine whether it came from the same stock as the pages before and after it in the record, and other aspects of recordation. One can well imagine the great flair with which a plaintiffs attorney would introduce such a gentleman into the courtroom together with blow-ups and equipment to demonstrate for the jury in detail the scientific analysis that he undertook in arriving at the conclusion that the doctor had attempted to "pull one over on them." If his evidence is convincing, the doctor's credibility with the jury will be lost. A judgment which may have been in his favor may go againtst him. A judgment for relatively minor injuries may be compounded many times to an amount that far exceeds the value of the case. In short, the public does not condone deception.

Perhaps the best method of demonstrating the harm that can occur is through a case example. In one such circumstance, a gentleman filed an action against his physician's alleged delay in diagnosis of a potentially cancerous colon lesion. As a result of the delay, it was asserted that he was forced to undergo a colostomy. Earlier intervention would have allowed a much simpler procedure to remove the lesion. During the trial of this case, the physician testified from what he alleged were his original office records. These were brought to the courtroom and demonstrated to the jury. The issue in the case was when the patient had first complained of rectal bleeding. The patient indicated that his first complaint was in November of 1973 and that he continually phoned the physician thereafter to reassert his complaints. The physician, on the other hand, demonstrated that his records recorded the first complaint as being March of 1974 and that in a subsequent visit in the same month; the patient indicated that there was no further evidence of bleeding. The patient, however, could not recall any such second visit or conversation with the physician where he denied the continuance of bleeding. Throughout the trial the accuracy of the medical records was stressed in support of the physician's position. The jury concurred and returned a verdict in favor of the doctor. However, shortly after the trial, the plaintiffs' attorney retained an investigator to go over the records in some detail. The investigator learned that the critical page of the records was on a form that had not been manufactured until two years after the date of the earliest entries on it. When confronted with this evidence, the physician was forced to admit that it was not his original record after all, but a copy made by him after the institution of the suit. As a result, the court held that to allow the verdict to stand would be a "gigantic injustice" and overturned the verdict in his behalf.

The above-referenced case is an example of a situation where it appears the physician may have intended to mislead. The same result can occur, however, with an innocent intention if the alteration is performed incorrectly. As a result, if a correction needs to be made, the following rules should be kept in mind:

Step 1. Any entry or document may be recopied in a more legible form (for example, typing) if this is routinely done to all such entries or documents for patients in the doctor's practice.

Step 2. An entry or document may be recopied in a more legible form (for example, typing) even if it is not the routine of the physician's office, as long as the original document is maintained with the copy.

Step 3. No alterations should be made to the original document once litigation has commenced or there is a reasonable suspicion that a claim will be asserted against the physician.

Step 4. Alterations may be made to the original document in the absence of litigation or suspicion that a claim will be asserted, but only in the following fashion:

a) Mark through the original entry with one line so that the entry may still be read.

b) The marked through entry should then be initialed and dated.

c) The corrected entry should then be made on the chart. The entry must be initialed by the person making the entry and dated so that it is clear when the correction is being made. If relevant, the hour of the correction should also be entered in the record.