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The Colorado Court of Appeals recently considered whether a physician could be disciplined for altering a patient‘s medical record. After finding that record keeping by a physician constitutes the practice of medicine, the court determined that a physician can be disciplined for inappropriately altering a patient‘s medical record.

 

In Colorado State Board of Medical Examiners v. McCroskey, a patient presented at Denver General Hospital emergency room with a stab wound. He was admitted to the hospital and bled to death several hours later. After the patient‘s death, the doctor revised a note in his record regarding his estimated blood loss. The patient‘s estimated blood loss, which was originally recorded to be 3,000 ccs, was erased and rewritten as 2,000 ccs. Dr. McCroskey also added a staff note to the record, which he backdated as if written on the date of the patient‘s death.

 

In Colorado, a physician can be disciplined for unprofessional conduct if he engages in two or more acts which fail to meet the accepted standard of medical practice. To determine whether McCroskey’s actions constituted unprofessional conduct, the State Board of Medical Examiners referred the matter to an Administrative Law Judge.  This judge concluded that many physicians backdate medical records and that he did not violate the accepted standard of medical practice by postdating an entry in his patient‘s chart. However, the judge did find a violation based upon Dr. McCroskey's alteration of the estimated blood loss.

 

Since the judge found only one violation, he recommended that no discipline be imposed.  The State Board of Medical Examiners did not agree with the judge's findings. They believed that backdating a medical record fell below accepted standards of medical practice and was a second violation. Based upon their findings, the Board issued Dr. McCroskey a letter of admonition. McCroskey appealed.

 

The case went up to the Colorado Supreme Court, back down to the Administrative Law Judge, and to the Colorado Appeals Court at various stages along the way. Ultimately, the Colorado courts found that the State Board of Medical Examiners could exercise its own judgment about whether a physician's actions violate the standard of care.

 

This standard varies according to state regulation. In Massachusetts, for example, the standard is less specific and perhaps more favorable to physicians. To discipline a physician, the Board must show that the doctor was negligent on repeated occasions or grossly negligent on a particular occasion.

 

In Colorado Medical Examiners v. McCroskey, the court rejected the argument that documentation is not treatment and the Board's purview is limited to oversight of treatment. The court stated clearly that the preparation of medical records is integral to the practice of medicine.

 

In any state, the preparation and preservation of medical records is a critical aspect of patient care. The medical record provides the treating physician and other health care providers with an accurate and detailed picture of the patient‘s health as of the date and time recorded.  The ultimate goal should be the maintenance of an honest, accurate, and concise statement of the physician's findings, diagnosis, and treatment  of the patient. If additional information should come to the practitioner's attention, then a new entry with a new date should be recorded. If an error is made in the record, then the incorrect information should be crossed out with a single line so that it is still discernible. A new accurately dated and timed note of corrected information should then be entered.

 

What looks bad to plaintiff lawyers and juries are records that contain erasures, White-outs, or obliterated entries. In that event, even excellent care is difficult to defend if it looks like a caregiver tried to change the facts or cover something up.


Punishment for Altered Records

by Attorney Frank E. Reardon

October 1997

Healthcare Law, Litigation & Public Policy   Medical Licensure & Discipline ♦ Employment Board of Registration

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