Four simple steps to proving that your doctor fudged your medical records

A doctor who fudges the medical records, adding or revising information after the fact, is in deep trouble. Nothing can be more damning than proof that a doctor, physician’s assistant or nurse practitioner has altered medical records to cover-up their negligence. But how do you prove it?

Step #1: Send out requests for the medical records of all of your treating physicians. Let’s say you begin treating with a nephrologist (kidney doctor), the nephrologist will request a complete set of your medical records from your primary care physician. This is a routine request, and the records administrator for your primary care physician will send your records to the nephrologist.

When you ask for the records from the nephrologist, you do not want to limit your request to the records made by the nephrologist. You want to specifically ask for all records contained in your chart, i.e., records obtained by the nephrologist from the primary care physician. These records may not be provided to you unless you specifically ask for them.

The records that the nephrologist obtained from your primary care physician will give you a “baseline”. The “baseline” is a set of the primary care records that you can use to compare to the set of your records produced by your primary care physician. This brings us to step #2.

Step #2: Once you have all of the records of your treating physicians, you can compare those records to those produced by your primary care physician.

Remove the primary care records produced by your nephrologist and compare them to the records produced by your primary care physician. Voila! You notice differences between the primary care records produced by your nephrologist and those provided by your primary care physician.

The primary care records that you secured from your nephrologist do not contain the “Cover Your Ass” (“CYA”) notations that are set forth in the records you got from your primary care doctor. For example, the primary care records that you received from your primary care physician state, “patient instructed to go to the hospital immediately if symptoms continue”. This is a classic “Cover Your Ass” notation that is often added to medical records after the date of treatment–the patient is being blamed by the doctor for failing to get follow up care. However, the same set of primary care records that you obtained from your nephrologist do not contain the CYA notation. Now, you’re getting somewhere!

Step #3: Request an appointment with the medical records administrator from your nephrologist’s office. At this meeting, you should inquire when the nephrologist requested the records from the primary care physician. Every doctor’s office should have a procedure for documenting the date that they receive medical records from other physicians, such as a date stamp on the records. Once you establish when the nephrologist received the primary care records, you can then prove that the CYA notation was added to your records by the primary care physician sometime after your nephrologist received the records.

Be especially nice to the medical records administrator at your nephrologist’s office, because he/she will be the star witness at your trial.

Step #4: Now, you have the goods against the doctor for forging your medical records and you are ready to strike. The last thing you want to do is tell the defendants that you have the goods on them. You want the opposing side to learn about the forgery for the first time at your trial.

Make huge enlargements of the medical records containing the CYA notation and the primary care records provided by the nephrologist that do not contain the CYA notation. At trial, you can have the medical records administrator testify about the date that he/she received the primary care records from your primary care physician and that the set of records that he/she received did not contain the CYA notation. This is devastating stuff! The defendant/primary care physician is now crawling under his table and looking for the fastest exit from the courtroom.

Now you’ve got devastating proof for your trial!

There is very little that is more devastating than proof that the defendant/primary care physician forged your medical records with “Cover Your Ass” notations in your medical records. Doctors forge medical records more than you’d think, but proving it is another matter. Now you have the 4 simple steps for proving that your doctor forged your medical records.

What you can do if you have any questions

If you have any questions or just want to chat, I welcome your phone call on my toll-free cell at 1-866-889-6882 or you can send me an e-mail at jfisher@fishermalpracticelaw.com . You are always welcome to request a FREE copy of my book, The Seven Deadly Mistakes of Malpractice Victims, at the home page of my website at www.protectingpatientrights.com.