Legal and regulatory proceedings

Navigating legal or regulatory processes

The medical record: A legal document — Can it be corrected?

An article for physicians by physicians
Published October 2009
IS0997-E

Abstract

Physicians should exercise care in modifying or correcting medical records. Suggestions on when and how to go about this are provided.

Of interest to all physicians

The medical record contains valuable information about a patient's medical history and individual clinical interactions. Such information supports the ongoing care for the patient by the physician and other providers.

In addition to its clinical significance, the medical record is also a legal document that can serve as evidence of the care provided. A record appropriately created at the time of the encounter and properly maintained contributes greatly to the successful defence of a lawsuit, or in responding adequately to a complaint to a regulatory authority (College).

Generally, courts and Colleges have mandated that, among other things, medical records should be factually accurate and legible.

Modifications of the medical record

Questions concerning whether a medical record was contemporaneous or modified arise from time to time in the course of proceedings before the courts and the Colleges. A review of these CMPA cases from 2003–2007 indicate that the most common issues arising from the modification of medical records were:

  • The record was created a significant time after the clinical care was provided.
  • A lack of awareness as to how to appropriately modify a deficient medical record. The circumstances most frequently cited for such modifications were:
    • To correct a factual error
    • At the request of the patient, where the patient objects to the physician's conclusions
    • In response to an adverse event, litigation, College complaint or investigation
  • In exceptionally rare cases, the physician was found to have created a knowingly inaccurate record.

The following two case studies illustrate important points to consider if you think it necessary to correct the medical record.

Case 1:

A 35-year-old male truck driver presented to a walk-in clinic complaining of back pain after having fallen from his truck earlier that day. On physical examination, there was tenderness of the lumbo-sacral spine, and limited range of motion in all directions. His neurological exam was normal. The physician prescribed analgesics and recommended follow up with the patient's own family physician and also a referral to a physiotherapist. 

During the visit, the patient asked the physician to complete a work-related injury form. When the physician suggested the patient take the form to his own family physician, the patient became argumentative. Feeling intimidated, the physician authorized modified work duties for a period of two weeks. Unable to reach his family physician, the patient returned six days later asking the physician to extend the disability period. When the physician declined, the patient became verbally abusive and threatening. He requested and was given a copy of his medical record. 

Sometime later, the physician added the word ‘today' to the medical record of the first encounter to confirm the timing of the initial injury. He wanted the patient's medical record to be accurate should the workers' compensation agency question the worker's entitlement to benefits and request precise details concerning the date of the injury. 

A few weeks later, the patient complained to the College about several aspects of the physician's care. In the course of the College's investigation, the patient's copy of the medical record was compared with the doctor's copy, and the addition, the word "today," was discovered. Although the College was satisfied with the care provided, it found the method by which the changes were made to the record was not acceptable, despite the physician's intention to make the chart complete and accurate. 

In emphasizing the need to sign and date any changes to medical records, the College stated, "While the Committee is not concerned that these changes to the chart were made for any improper purposes, nevertheless, because of the serious consequences that unattributed changes to medical records can have, the Committee will caution [the physician] with respect to changing medical records after the fact, and to ensure that, in future, he and/or his staff sign and date such changes."

The physician was therefore criticized not for refusing to complete the form but rather for making the changes to the medical record in an inappropriate manner.


Case 2:

A 50-year-old man presented to a locum physician complaining of generalized aches and pains, reduced appetite, and headache. He also had a history of depression and was under the care of a psychiatrist.

On examination, there were no findings indicative of an underlying physical problem. The physician believed the patient's symptoms were manifestations of his depression. She wrote "depression" as her diagnosis in the medical record. The patient, who was infuriated by this diagnosis, became intimidating and declared that the physician, who was not a psychiatrist, could not possibly make such a diagnosis. He threatened to report the physician to the College and demanded to amend his own medical record.

The physician refused to allow this. The patient had another outburst, told the physician she was irresponsible and threatened repeatedly to report her to the College. Finally, to placate the patient, the physician crossed out the word "depression" and wrote "I don't know what's wrong with the patient."

The patient complained to the College about, among other things, the physician's modification of the record. Although supportive of the clinical care, the College found that it was unacceptable to change the record by "scratching out notes…because of a perceived aggressive patient." It found that "the notes made by the physician failed to adequately document the interaction between the parties." The College recognized that "there may be some patient interactions that result in emotional confrontations that may be challenging for the physician to manage. If there was some resistance to the diagnosis of depression expressed by the patient during their discussion, the Committee would expect the physician to document this information, but would not expect the physician to alter the record to ‘placate' the patient."


Risk management suggestions

The Colleges and courts have emphasized the importance of medical records that are contemporaneous, are an accurate representation of events and are adequately maintained.

It may be necessary to modify an existing medical record at the time of an entry or later for a variety of reasons. For example, upon review of a clinical note you dictated, you may discover an obvious error in the transcription. Any changes should be made according to applicable regulations and guidelines, such as the general advice or policies published by your College.

How to correct a medical record

Corrections or modifications should only be made to your own entries. Questions about notations made by other professionals in the chart should be raised with that individual.

In the event that it is necessary to subsequently add or modify your entry in a patient's medical chart, most Colleges recommend that the changes be dated and signed (or initialled) or, in the case of electronic records, authenticated. Many Colleges state that when amending a clinical record, the original entry must not be destroyed or obliterated. In other words, if an amendment is made to the record, it should be a legible supplement to the original entry.

If your College permits the incorrect information to be severed (or stored separately) from the record, a notation must allow the incorrect information to be traced. If the incorrect information is left on the record, it should be clearly noted as being incorrect. This can be accomplished in many cases by simply making a single line across the original entry, followed by the supplemental entry that is signed and dated. Consider adding an addendum in the progress notes if you feel the existing record is inadequate and more space is required. An addendum should be clearly labelled as such and include the current date, the additional information and your signature.

Guidelines or recommendations for the modification of paper records can present a challenge when applied to some electronic records. Colleges and privacy commissioners recommend or require that electronic health records management systems have an "audit trail" that tracks who made the change and when. The system should also be capable of making the change without deleting the original note from view.

Correcting, changing, tampering or adding to a medical record after learning of a legal action, even of the threat of a legal action, or a complaint may be seen as unprofessional and will likely undermine your credibility and defence. 

Modifications of the medical record by patients

Generally speaking, patients should not be permitted to unilaterally modify a physician's entry. While a patient can request that the record be changed, the physician ultimately must agree that the request is necessary to correct an incomplete or inaccurate record. As the above cases illustrate, the Colleges will assess whether it was appropriate to change the physician's note. In one of the cases, the College found that it was insufficient justification to change the record simply because the patient was being difficult or confrontational about the entry. In such a situation, the College suggested that it would have been preferable to document the events, including the discussion with the patient and/or staff. In some jurisdictions, privacy legislation requires the patient's objection to the entry to be included as part of his/her medical record.

Manage your risk

If in doubt, consider contacting the CMPA for further advice before correcting a medical record. In addition, you may consider consulting with your College for any addition requirements or recommendations in this regard. Across the provincial/territorial Colleges, the following are some of the most common suggestions or requirements when considering correcting your entry in a patient's medical record:

  • Is the information in the medical record relevant and accurate?
  • If a change or addendum is necessary to your entry, have you dated and signed the supplemental entry?
  • Have you made the change in a way that preserves the original entry?
  • If you do not agree with a change requested by a patient, have you made a note of the patient's request and date in the medical record? Does it include the date of your entry, your reasons for refusing to modify the entry, and your signature? Have you discussed the decision with the patient?

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.