Dr V received a request for a copy of a patient’s records from a group of attorneys; he didn’t feel he was at risk so he disclosed the records without informing MPS. Two years passed before he received a summons.
Realising he was to be the subject of a clinical negligence claim he then contacted MPS for assistance and our lawyers requested a copy of the patient’s records. By this time, Dr V had forgotten the original request from two years previously so when he reviewed the records prior to sending them to MPS, he realised they were somewhat scanty and decided to embellish them. Dr V had no intention to mislead, but he wanted to add extra clarity for the lawyers, and enhance his own reputation to the defence team.
One year later, MPS started to prepare a defence based on the records disclosed to us; our case collapsed when our “original” records were compared to the claimant’s copy of the true original records.
Had Dr V not tampered with the records, this would probably have been a defensible claim.
This case demonstrates the value of keeping detailed and accurate contemporaneous medical records. There is a popular misconception that no – or very scanty – records can work in your favour and make a case difficult to prosecute. This can be the case but it is also more difficult to defend a case – where it might be difficult for the claimant to show there was negligence, it makes it just as difficult for MPS to show that the patient was managed appropriately. The adage “no records, no defence” has a ring of truth to it.
Furthermore, if you need to add something to a medical record or make a correction, make sure you enter the date of the amendment and include your name, so no-one can accuse you of trying to pass off the amended entry as contemporaneous.
There is only one thing more damaging than absent or poor notes and that is fabricated notes
Do not obliterate an entry that you wish to correct – run a single line through it so it can still be read. There is only one thing more damaging than absent or poor notes and that is fabricated notes.
You must always inform MPS if there has been a request for records where there is even a remote risk of litigation.