PLEASE! Don’t go back and change the health care records after a bad medical outcome. Jurors in Atlanta in late 2022 awarded a $75 million verdict against a pair of Georgia hospital physicians who did just that. The 32-year-old male patient was taken to the ER. It was alleged the physicians failed to diagnose a brain stem stroke for over a day causing catastrophic paralysis.

The patient’s family alleged the ER physician went back and altered the medical records when he learned of the patient’s true condition. This proved to be critical to the outcome of the case. Plaintiff’s counsel told the jury: “We’re in this case, folks, for one reason: because this note [by the ER physician] got changed.”

The bottom line is that juries will punish changing medical records. It simply is not a good idea:

  • Falsifying a medical record is a crime punishable by a fine or even jail time. Altering records make it difficult for health care providers to win medical malpractice cases.
    • Liars are not trusted by juries, and a questionable change to a record implies that something is being covered up.
    • The consequences of getting caught altering a medical record can be worse than the consequences of telling the truth.
  • It is all but impossible to get away with falsifying medical records.
    • Discrepancies can be noticed among different copies of a document as well as in a patient’s medical bills.
    • Forensic scientists can tell when a written document has been changed by looking at inks and indentations in the paper.
    • Changes in electronic records are evident in the audit trail of the data.

It is not illegal for medical professionals to make honest updates to records, as long as they are properly designated: Make a new note with the current date/time, labeled “Late Entry,” “Correction,” or “Addendum,” explain the reason for the change and any new information, and a line should be drawn through the incorrect entry—the text, however, should still be legible.

The following verdicts and settlements are other examples of lawsuits concerning falsifying medical records:

  • 2020, Kentucky: $5,000,000 Verdict. A nursing home admitted an 85-year-old woman. Its staff designated her as a choking risk. Four months into her stay, she experienced two choking incidents within 24 hours. Three months later, it happened again. The nursing home staff found her unresponsive, and she died. Her family alleged the nursing home staff posthumously altered her medical records by omitting the fatal choking event. The family’s forensic document expert concurred.
  • 2019, Pennsylvania: $3,380,000 Verdict. A toddler was treated for vomiting in the ER and the next morning was pronounced dead. Her bowel had strangulated due to a severe hernia. She had been vomiting bile which indicates bowel obstruction and a surgical emergency. It was discovered that “bilious vomiting” was written on the girl’s medical record but was later removed. Due to the altered medical record, the court granted the parent’s motion for an adverse inference charge: the fact the hospital felt compelled to alter the medical record indicated that it must have contained unfavorable information.
  • 2018, Texas: $7,635,000 Verdict. A 14-year-old girl committed suicide shortly after her pediatrician prescribed a medication to treat her depression. When the mother requested medical records from the pediatrician’s office, she discovered that the defendant pediatrician had altered her daughter’s records to indicate he had warned them the medication could cause suicidal thoughts. The result was two sets of records that didn’t match.

Each of these verdicts was likely larger than it otherwise would have been had the records not been altered. If an alteration of medical records can be proven, the case becomes unwinnable, and it is very likely the jury will punish the deception with a large verdict.