The medical record contains valuable information about a patient's medical history and individual clinical interactions. It is also a legal document that can serve as evidence of the care provided and discussions with the patient. A record 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 medical regulatory authority (College) or healthcare institution.
Generally, courts and Colleges have mandated that, among other things, medical records should be accurate, relevant, and complete.
Modifications of the medical record
A 35-year-old truck driver presented to a walk-in clinic complaining of back pain after having fallen from their truck earlier that day. On physical examination, there was tenderness of the lumbo-sacral spine, and limited range of motion in all directions. Their neurological exam was normal. The physician prescribed analgesics, recommended follow up with the patient's family physician, and provided 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 their family physician, the patient became argumentative. Feeling intimidated, the physician authorized modified work duties for a period of two weeks. Unable to reach their 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. They requested and were given a copy of their 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. They 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 of 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, they and/or their staff sign and date such changes."
A 50-year-old presented to a locum physician complaining of generalized aches and pains, reduced appetite, and headache. They also had a history of depression and were 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 their depression. They wrote "depression" as their 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. They threatened to report the physician to the College and demanded an amendment to their medical record.
The physician initially refused to amend the record. The patient had another outburst, told the physician they were irresponsible and threatened repeatedly to report them 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."
The College 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."
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 professional.
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. Hospitals may also have their own policies that physicians must follow when modifying records.
Privacy legislation also prescribes certain requirements when correcting a medical record. For example, in certain circumstances custodians are required to inform those who received the original record of the correction later made to that record. If your College and the applicable privacy legislation permit 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.
Most Colleges and privacy commissioners generally recommend or require that electronic health records management systems have an "audit trail" that tracks who made the change and when the change was made. The system should also be capable of making the change without deleting the original note from view.
Amending a medical record after learning of a legal action, 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 requested by patients
While a patient can request that their record be changed, the physician ultimately must decide whether the request is necessary to correct an incomplete or inaccurate record. Physicians must make this decision in accordance with principles set out in applicable privacy legislation, which may, for example, expressly allow physicians to refuse to make the requested change where the record is a professional opinion or observation. Privacy legislation also generally requires that custodians provide the patient with written reasons for any refusal to make the requested correction.
As the case scenarios illustrate, Colleges will assess whether it was appropriate to change the patient record. In one case, 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 that situation, the College suggested 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 their medical record.
Manage your risk
A review of College guidelines and provincial and territorial privacy statutes suggests that the following should be considered when correcting your entry in a patient's medical record:
- Is the information in the medical record relevant, complete, and accurate?
- If a change or addendum is necessary, and 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 the note 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?
- Have you complied with any applicable statutory privacy requirements to provide reasons for a refusal to change the record?
If in doubt, consider contacting the CMPA for further advice before amending a medical record. Physicians are also encouraged to review their College’s requirements with regard to the amendment of medical records.