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Tamper Detection in the Medical Record

A Certified Legal Nurse Consultant is one of the best and most cost-effective resources you have at your disposal to discover tampering. We are intuitively thorough and attentive to the smallest details. Discovering evidence of tampering can be a windfall for the plaintiff and the kiss of death for the defendant. The following are a few signs to watch for.

changes in slant, pressure, uniformity or other differences in handwriting
writing that appears crowded around existing entries
use of different pens in one entry
additions on different dates written in the same ink while original entries were written in different inks
different handwriting in what appears to be one provider's entry
dictated note that is typed weeks or months after the incident
unnatural order of writing and uniformity of handwriting, ink, margins and spaces
use of forms not in use at the time of the timed entry
substituted or rewritten records
significant information is omitted
no documentation of the significant event
erasures or obliterations

Even a marginal case gets better when evidence of tampering is present. If parts of the medical record are damaged, changed or destroyed, juries will assume that the information on the missing documents was so damaging that the healthcare provider had to destroy it.



Tamper Detection in the Medical Record A Certified Legal Nurse Consultant is one of the best and most cost-effective resources you have at your disposal to discover tampering. We are intuitively thorough and attentive to the smallest details. Discovering evidence of tampering can be a windfall for the plaintiff and the kiss of death for the defendant. The following are a few signs to watch for. changes in slant, pressure, uniformity or other differences in handwriting writing that appears crowded around existing entries use of different pens in one entry additions on different dates written in the same ink while original entries were written in different inks different handwriting in what appears to be one provider's entry dictated note that is typed weeks or months after the incident unnatural order of writing and uniformity of handwriting, ink, margins and spaces use of forms not in use at the time of the timed entry substituted or rewritten records significant information is omitted no documentation of the significant event erasures or obliterations Even a marginal case gets better when evidence of tampering is present. If parts of the medical record are damaged, changed or destroyed, juries will assume that the information on the missing documents was so damaging that the healthcare provider had to destroy it.		The old saying "If it wasn't charted, it wasn't done" still holds true today. Nurses are the most knowledgeable professionals regarding documentation in the medical record. A Certified Legal Nurse Consultant is your first line of defense in detecting tampering and may save you the cost of a Forensic Document Examiner.