Part I – Altered Medical Records
If you believe that a doctor or hospital has committed medical malpractice or hospital malpractice, the first thing you will need to do is obtain a copy of your medical record.
Many clients worry that any delay in securing copies of their medical records will provide their doctors or their hospital with an opportunity to alter the chart. They do not realize that an altered medical record is often the best gift that a bad doctor can give to his patient.
An altered medical record undermines the integrity of the chart. It immediately places the defendant in a medical malpractice case at a disadvantage by showing him or her to be unworthy of belief. Unfortunately, many medical malpractice lawyers simply do not take the time to examine the chart in order to see if it has been altered. Fortunately, most medical record alterations are easy to spot.
In thirty years of practice, I have never lost a case in which a defendant doctor altered the medical record.
Jurors understand that the alterations are themselves evidence of a guilty mind. Moreover, under Pennsylvania law, jurors are instructed that an alteration gives rise to an “adverse inference.” The court specifically instructs the jury that the alteration can be considered as evidence against the defendant with respect to just about any issue.
Consider a scenario in which a doctor who alters the patient’s chart so as to make it appear that she recommended testing that she actually never recommended. Proof of the alteration would become evidence (a) that the standard of care required such testing, and (b) that the testing would have made a difference in the outcome.