Can Doctors, Hospitals and Other Medical Professionals Alter Medical Records?
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Can doctors, health care professionals or hospitals alter medical records? It used to be the answer to that was absolutely. Now it’s a little more difficult and I’ll explain. At a time when medical records used to be hand drawn when a doctor would actually write in, in his or her own handwriting the history taken from a patient, it’s very easy to change those records because you could simply rewrite the page, substitute that one page and no one would ever know. Now with the advent of electronic records, and electronic records are when you receive hospital care now a-days everything is entered via computer into a record. We are able to obtain that computerized record. We are able to figure out when someone actually puts an entry into a record. So if someone comes back and tries to alter the record they leave a footprint or a thumbprint so we can find out what was altered, how it was altered, when it was altered and who did the alteration.
In the old days and still in some practices, the only way for us really to prove, and we’ve had several cases like this, where the patient/client would bring us in records that she or he obtained from the doctor’s office and then later on we would get a second set of records from the doctor’s office and when you’d compare the set that was brought in by the client with the set that we obtained from the doctor, you could see from time-to-time specific changes. That’s a clear alteration of medical records, it’s a violation of the law, but that’s one way to prove alteration and so that’s what we do.