To Delete or Not Delete: When Can Patient Records be Modified?

Maintaining complete and accurate patient records is a crucial component of quality assurance and clinical care. Whether a patient sees multiple providers or returns to the same doctor for routine visits, a patient’s records are fundamental to providing continuity of care, facilitating medical decision-making, and identifying health risks.

What happens when a patient’s record is inaccurate or incomplete, and you know it? Can you—and should you—modify the patient’s chart? What are the legal implications involved with modifying or neglecting to modify a patient’s records?

Here are some basic guidelines to follow when faced with these issues.

Medical Malpractice and Professional Licensure Implications of Patient Record Modifications
In Pennsylvania, it is not considered unprofessional conduct or a violation of state licensing statutes for a healthcare provider to correct information on a patient’s chart where:

• information has been entered erroneously, or
• a modification is necessary to clarify prior entries

However, any time a correction or addition is made, it must be clearly identified as a subsequent entry, and annotated with the date and time of its entry. Not only could failing to date a subsequent entry lead to confusion, but it also could be viewed as an attempt to obscure the fact that the patient’s record was previously inaccurate or incomplete.

Likewise, it is permissible to add information to a patient’s chart if the information was not available at the time of a prior entry. However, in order to avoid scrutiny, the addition must be identified and dated as such, and must be made within a reasonable time after discovering the additional information.

While these rules provide important guidance, they also leave several important questions unanswered. For example:

• When, if ever, is it permissible to delete information from a patient’s chart?
• What is considered a “reasonable time” to make modifications?
• If a patient’s chart has not been updated within a reasonable timeframe, what should a provider do with the information?
• What should be done if an error is discovered after it has influenced the patient’s care?

What are the Potential Ramifications of Improperly Modifying a Patient’s Chart?
In medical professional liability litigation, evidence that a physician has intentionally altered or deleted information in a patient’s record, without including the requisite annotations, can have direct and severe ramifications. Depending on the significance of the altered or deleted information, and the severity of the physician’s conduct, ramifications may include:

• preclusion of evidence
• an adverse inference instruction (i.e., the jury should infer that the physician committed malpractice based on his
• or her attempt to conceal the pertinent information on the patient’s chart), and even
• dismissal of a claim or granting judgment in favor of the prejudiced part

To make such a determination, the court must balance three factors:

1. the degree of fault of the party who altered or destroyed the evidence
2. the degree of prejudice suffered by the opposing party; and
3. the availability of a lesser sanction that will protect the opposing party’s rights and deter future similar conduct

In evaluating the first prong (i.e. fault of the party altering or destroying evidence), courts must consider both the extent of the offending party’s duty or responsibility to preserve the relevant evidence, and the presence or absence of bad faith.

With these concerns in mind, healthcare providers must make informed decisions about how and when to modify patient records, while being cognizant of the medical and legal implications involved. If a question exists, or clarity is needed, healthcare professionals should seek legal counsel to insure proper documentation procedures are followed and to mitigate risk.

Contact the Medical Professional Liability Lawyers at Burns White LLC
Do you have questions about altering patient records? Are you concerned about the implications of modifying, or failing to modify, a patient’s chart? To speak with one of our experienced medical professional liability lawyers in confidence, call 412-995-3000 or inquire online today.