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What happens if your doctor alters his medical records in a medical malpractice lawsuit in New York?

 

A:

If we can prove that the doctor altered his medical records, he could lose his license to practice medicine. It's that simple.

However, proving that can be very challenging.

Here is what I mean. Before starting a lawsuit, we are obligated to obtain your medical records, review them and then send them out to medical expert for full review. The records we obtain will be photocopies.

During my review of the records, there may be some concerns about whether the records were altered or changed. However, there is no way for me to tell definitively since I will not have access to the original handwritten records at that time.

If the doctor is using electronic medical records, this task becomes even more challenging.

Assuming you have a valid basis to proceed forward with a lawsuit, the only time I will have the chance to review the doctor's original medical records will be at his deposition. A deposition is a question-and-answer session given under oath at the attorneys office.

The doctor's deposition will take place many months after your lawsuit has been started.

The doctor is required to come to this question-and-answer session with his original chart. If the doctor has been handwriting his notes in a medical chart, I will look to see what type of pen or ink was used in the various notes in question, the structure of the notes, the timeline of when entries were made and whether all entries are in the same handwriting and the same ink and pen.

If the doctor is using electronic medical records, I now have to delve deep into the procedures for making entries into the computer; when the entries were made- during the office visit, after the office visit, days later or at some other point in time.

Many injured victims believe that the doctor or his staff may have altered their records once they have been sued. I will tell you that in more than 24 years of practice in New York, I have seen this happen only twice.

A FASCINATING STORY

Let me tell you a most interesting story involving a doctor who claimed he told the patient everything he needed to. Yet the patient swore up and down that the doctor never told her to follow up with cancer specialists and other important treatment options.

The medical records I had in my file had been faxed to the patient only days after her last visit with this doctor. She had requested those records so that she could take them and go to another physician for treatment. Before the doctor's deposition, I had studied those records and was aware of all the details contained in those medical notes. However, they were faxed copies of the doctor's notes.

On the morning of the doctor's deposition, I asked his attorney to see his original record. As I went through the doctor's chart, I noticed something very unusual. The information contained on various dates were entirely different than what I read in the notes contained in my file. They were markedly different.

I closed the doctor's original chart, thanked his attorney and then began to question the doctor without alluding to anything suspicious or out of the ordinary yet.

I questioned the doctor extensively about his original records that he brought with him. He admitted that these are his only records. He admitted that all the records were in his own personal handwriting. Nobody else made entries in the patient's chart and he made these entries at the time of the patient visit or immediately thereafter on the same day.

STRATEGY: I got the doctor to lock himself into a box where he had admitted that these were the only records for this patient. After I finished going through the doctors original chart, I pulled out my faxed copies of his chart.

THIS IS WHERE IT GOT INTERESTING

I handed the doctor the first note.

“Doctor, is this your handwriting?”

“Yes.”

“Do you know where the original note is for this faxed copy?”

“No I do not.”

“Doctor, this note for this particular date has different information contained here compared to the original note that you brought today that we already discussed. Can you explain how they are totally different?”

The doctor's mouth dropped, his eyes went wide and he said “No I can't.”

I went through every single note that I had in my file, which were the faxed copies of his notes and established that he had absolutely no idea how these notes were different compared to the notes he presented today at his deposition.

It was obvious to me that his attorney had no idea that the doctor had two totally different sets of records and knew nothing about it before this deposition. It was also apparent that the doctor had changed all of the patient's records to absolve himself of any wrongdoing. However, reading the notes I had my file it clearly showed the doctor failed to do what he should have done.