Changing the medical record is a serious crime in many states.
A healthcare provider who alters the medical record:
(1) can go to jail
(2) can lose his or her license
(3) can lose key insurance protection
(4) may be subject to additional damages
(5) will have seriously prejudiced the court or jury against his or her case
It can be very difficult to completely alter the medical record. The original report may:
(1) have a carbon copy
(2) have been faxed to someone
(3) have been xeroxed
(4) be in a computer backup
(5) still be recoverable from a computer hard disk if only deleted and not expunged
(6) have been sent over an interface to several other computers
(7) been sent from one office to another provider
(8) been printed several times
Making changes to handwritten notes can be hazardous if
(1) a different ink or pencil is used
(2) there are underlying pages that may be imprinted by the writing
(3) changes have occurred in the paper if significant time has passed since the notes were written
Other issues:
(1) Removing all traces of the original report may leave gaps in various records that will be scrutinized.
(2) No one else must know of or suspect the falsification.
