One of the most important part of every doctor’s responsibility to his patients, is to keep thorough and accurate records. Good record-keeping is no mere bureaucratic task. Medical records provide the patient’s history – critical in understanding the present – for the doctor who writes the records. They are relied upon by subsequent treating physicians to give an accurate picture of a patient’s prior medical history. No competent physician will deny the importance of accurate medical record-keeping.

Of course, well-kept medical records may contain evidence of bad medical practice, as well as the patient’s history. The foundation of most medical malpractice cases is found not in the patient’s memory, or the testimony of witnesses (though there are cases in which testimony of treating medical professionals is important), but in the medical records. Regrettably, the alteration or destruction of medical records by doctors in cases of medical negligence, is not as rare as should be. More often than is acceptable, medical professionals faced with a disastrous medical result due to their negligence, may try to revise history by altering or destroying records. Key records or laboratory reports may mysteriously disappear from the patient’s chart, leaving attorneys and forensic experts (not to mention subsequent treating physicians) to guess at exactly what happened. Sometimes a doctor fearing a lawsuit may attempt to delete harmful facts or add invented facts to the record, attempting to make the post-incident additions look contemporaneous with the original drafting of the records.

Sometimes a doctor has a legitimate reason for changing an entry in a medical record – for example if he realizes that his original entry was incorrect or insufficient. When that happens, the proper way to make the change is to make clear the date and time of the change and the reason for it, accompanied by the doctor’s signature. Evidence of record destruction or improper alteration is persuasive evidence that the doctor was aware of his medical negligence and was attempting to cover-up his actions. Reputable doctors undoubtedly regret that altered medical records to hide malpractice occur often enough that there is a term for the phenomenon – “doctored records.”

Unfortunately, destruction of medical records sometimes can defeat a legitimate medical malpractice action. Unless a plaintiff’s attorney, with the help of his experts, can make a credible case of what happened, without the missing records, the case may never make it into court, let alone to a jury. On the other hand, when a doctor is caught having destroyed or altered records, there is a risk that a jury will be angry and award a much larger verdict than it otherwise might have. When the evidence of record destruction or alteration is strong, the doctor’s insurer will usually try to settle for a high-end amount.

Doctored medical records can be uncovered in a number of ways. Sometimes, the alteration is obvious even to an untrained eye, and when the doctor is deposed, his explanation for the change is implausible. In one birth trauma case I handled, critical entries were missing from the doctor’s notes. At his deposition, he testified that his secretary had spilled coffee on the document and that he accidently scrubbed off the entries while trying to blot the coffee. The case settled shortly thereafter. If the alteration was handwritten and occurred long enough after the original recordation, a document examiner may be able to show that the notations were made at different times, by analysis of the ink used or the handwriting itself. Sometimes two versions of the same record are uncovered – rare, but devastating to the defense. Attorneys should be alert for the possibility of document alteration or destruction in every medical malpractice case. When discovered, alteration greatly increases the value of any recovery.