Tampering with Medical Records Can Have Grave Legal Consequences

Medical records are sometimes intentionally falsified for various reasons, and any tampering is revealed through an exhaustive medical records review. Whatever be the reason, anybody caught for tampering the records will have to face serious penalty. Medical negligence occurs in a number of medical settings with statistics showing that more than 400,000 Americans are killed every year because of preventable medical errors. Now, the VA (Veterans Administration) medical care system is also proving to be negligent towards veterans, posing huge threats to their health, safety and lives.

We have been reading news regarding neglect and abuse at the VA over the past several years, mostly those pertaining to neglect/abuse in the VA disability process. Now we also hear news regarding VA medical negligence in the care of veteran patients. These include wait times for appointments and falsified waiting lists. Apart from healthcare providers, the parties at fault also include staff and administrators, often misguided.

In a recent incident, a 51 – year – old U.S. Department of Veterans Affairs employee was sentenced to 27 months in prison followed by 3 years of supervised release.

This person was found guilty of 50 counts of making false statements to a federal agent. This former Chief of Non – VA care Coordination at the Charlie Norwood VA Medical Center in Augusta was indicted on 50 counts of ordering his staff to falsify the medical records of more than 2,700 VA patients waiting for approval for medical care such as neurology services, surgery, mammograms, imaging and ultrasound, outside the system. He was entrusted with the duty to ensure that these patients were properly referred to for doctor’s appointments.

In May 2013, the national office had issued a mandate to close all open consults-orders for specialized medical services and diagnostic tests. More than 30,000 of the 2.1 million open consults were in Augusta Georgia, and each medical center had a year to complete the task.

• The sentenced employee was sent 2,700 veterans’ files and ordered to close out the consults two weeks before he was to start a new job at another veterans’ affairs facility.
• He deliberately closed the unresolved consults as “patient refused services or services provided,” whereas these medical appointments had not been scheduled or completed.
• In addition, he lied to the investigating agents regarding his actions.
• It was found that he chose to manipulate veterans’ medical records to give the false appearance that the number of incomplete consult appointments was lower than the actual backlog, thereby putting veterans at risk.

Indeed, news such as this is quite disturbing when you think of how the health and lives of veterans may be at risk. When patients suffer, are injured or die at a VA hospital, it leads to medical malpractice and wrongful death claims against the hospital. All the following can be instances of malpractice when they lead to injury or death of a patient:

• Deliberate delays in providing treatment
• Falsifying medical records
• Withdrawing from treatment responsibilities
• Refusing to provide treatment in a medically acceptable manner

Medical records review is an important process in the event of a malpractice lawsuit, and this is why accurate and detailed medical documentation is very necessary for the physician or other party concerned to defend himself. Accuracy can be ensured only if each addition to patient records is marked with the date and time that correspond to the medical service or treatment being described. Apart from this, it is also important that additional notes are incorporated explaining what accounted for the delay in making the entry. While accurate medical records are the best tools to defend oneself if there is a medical malpractice claim, deliberate tampering with the medical records can be most dangerous.

Veterans are protected by the FTCA (Federal Tort Claims Act), which allows them to file a claim against VA medical centers for sub-standard treatment. As a medical claims review company providing service to personal injury and medical malpractice lawyers, we understand that the claim has to be filed within 2 years from the date the injured person knew/should have known of his/her injury. In this case any type of state law limitation period does not apply. People missing this vital 2 – year limitation could have their claim dismissed. When there is a suspicion of medical negligence and resultant harm, the review of medical records to establish injury and also identify falsified and missing records becomes a very important though time-intensive process. That is when medical record review for attorneys becomes a good support service for legal professionals preparing and arguing personal injury cases for veterans.