The patient’s chart is supposed to be the official medical record for assessing and diagnosing, delivering treatment and providing care. Documentation also is the basis for payment and for monitoring quality of care. If it isn’t written down, it doesn’t matter whether the physician asked the patient about smoking cessation or the nurse provided hospital discharge instructions. For all intents and purposes, it doesn’t count unless it’s documented.
It almost goes without saying that the patient’s medical record should be complete and accurate. If worse comes to worst, good documentation can help practitioners defend themselves if there are ever complaints about the care they provided or if they’re sued. It’s an axiom that health care professionals have had drilled into them: Document, document, document.
There’s another, and darker, side to this corollary, though: If you don’t document it, you can pretend it didn’t happen.
It’s one of health care’s dirtier little secrets that the medical record can and does get fudged. How often does this happen? It’s impossible to know for sure, although it doesn’t seem to be a commonplace occurrence. A good share of the time, it’s probably unintentional. But there also are times when fudging is deliberately used to obfuscate the facts, especially when something hasn’t gone well with the patient.
Consider the story of Dr. Tricia Pil. Five years ago Dr. Pil underwent a difficult, traumatic labor and delivery, an experience she recounted recentlyÂ for the patient-safety advocacy organization known as Pulse. One of many disturbing aspects of her story (and it’s unmistakably a very disturbing story) is the repeated discrepancy between her own recollection of events, the official version that appeared in her medical chart and the hospital’s version of what allegedly happened. Here’s an excerpt:
Patient: We are moved to the postpartum floor. Seven hours later, I suddenly feel weak, dizzy and nauseated. I say, “Somebody help me, I don’t feel well.” The next minute, I’m hemorrhaging. There is blood spurting everywhere, clots the size of frying pans. I think I am going to die. Panicky nurses and residents crowd the room. The crash cart is wheeled in, my baby is wheeled out. My husband is shouting, “Somebody get Doctor B!” I am being stuck everywhere for an IV…
Chart: 7:30 a.m.: Called to see patient passing clots. Passed two medium size clots. Blood pressure 110/67… 100/60… 90/58. Pulse 88… 96. Patient uncomfortable, vomited x2…
Hospital: Once again, we refer you back to to your private physician for a detailed discussion about the hemorrhage you outlined.
Dr. Pil’s newborn son loses weight and starts to vomit while in the hospital. Mother and baby are sent home anyway, but return to the emergency room the same day after the baby vomits more severely and becomes jaundiced and dehydrated.
Patient: My son remains hospitalized, lying in an incubator receiving intravenous fluids and phototherapy. He doesn’t come home for good until he is nearly a week old, requiring yet another week of home phototherapy and daily home care visits before regaining his strength and weight.
Chart: Diagnosis: Obstetrical Trauma Not Otherwise Specified. Disposition: Return in approximately one year – Dr. G.
Hospital: We are sorry that you were so unhappy with your stay. After a thorough investigation of your allegations, we have concluded that the care you received was appropriate. Thank you for taking the time to express your concerns.
Granted, we’re seeing only a limited slice of what happened, not the whole story. But if the only version you saw was the one recounted in the medical chart, how much of the story would be missing, and how accurate would it be? Would you have any sense of what truly happened to this patient or how deeply she was damaged by it?
Sadly, judging from the online feedback to Dr. Pil’s story, this gap between the official record and the patient’s actual experience does not appear to be a single isolated incident. Many of the commenters didn’t even seem surprised by it. “If what you experienced was not malpractice, the collusion between doctors, staff and the hospital after the fact certainly was,” one person wrote. “As a nurse I felt ashamed reading the negligent, evasive and uncompassionate details of the staff,” someone else wrote.
Dr. Pil’s story was picked up last week at Kevin, MD, where the online discussion continued. One commenter recounted having “a frightening C-section” during which the epidural didn’t completely take effect. When she asked for a copy of her medical record afterwards, she found this report from the OR: “patient tolerated the procedure well.”
From another commenter:
When you check your medical records, do you see anything that doesn’t jive? Times, doctor’s orders, procedures, signature page. Every order and comment needs to be validated throughout the chart. I’ve had cases where the nurse has gone in the week after a patient died in the ER and inserted charting to cover everyone’s butt. She messed up and actually put the current date on the notation. I’ve also been fired for refusing to falsify a patient’s chart.
To be sure, the medical record is meant to be objective and dispassionate. To patients and families who are upset or traumatized about something that happened with their care, plain statements of fact can unintentionally come across as callous. What health care providers have been slow to recognize, however, is the extent to which the patient’s and family’s perspectives are excluded from the official record.
It isn’t just patient care that’s at stake when the chart is fudged. The truth, or at least a wider view of events, can be a casualty too. Officially, Dr. Pil was described in her chart as being “uncomfortable” after her post-delivery hemorrhage. According to her own account of events, though, she was clearly far more than uncomfortable. And if the hospital’s investigation of her complaint was so thorough, why didn’t it seek a statement and narrative from Dr. Pil and her husband, who, after all, were key witnesses? Based on the details in her story, it appears she wasn’t even allowed to challenge the accuracy of her medical record, let alone the conclusion that her care was appropriate – and herein lies the snare in which patients are entangled.
When the chart is viewed as the official record of the patient’s care, it becomes very difficult for patients to question or disprove its accuracy – especially since they have almost no say over what goes into their medical record in the first place. In fact, unless patients specifically ask to see their record, they’re unlikely to even know if it’s inaccurate or incomplete. Disagreements can boil down to a case of he said-she said, and patients and families generally are the losers in this scenario. Even when they’re smart, credible witnesses of what happened, it’s all too easy for providers to disbelieve them or to dismiss them as laypersons with no real understanding of what they saw or experienced. Although falsifying a medical record is a felony in most states, offenders are seldom prosecuted except in the most blatant cases.
I’d like to be able to say I don’t often come across stories such as that of Dr. Pil. Unfortunately it’s not unknown by any means for medical records to be at odds with the patient’s and family’s own memory of what happened. Patients and families can be mistaken, of course, but neither is the medical record infallibly correct. Records can be incomplete. Salient facts can be selectively omitted or glossed over. Records can be altered after the fact or sections of the record can vanish. Sometimes insurance fraud is involved, but other times medical records are tampered with for the sake of covering up an error, bad judgment or simply a situation that might be negatively interpreted if the patient, family or an attorney ever saw the chart.
This isn’t just a case of disgruntled patients or trigger-happy lawyers making unfounded accusations. Medical professionals themselves, if they’re being honest, will admit that sometimes medical records are falsified. This case study, which appeared in 2001 in the British Medical Journal, sparked considerable discussion when it first appeared and is now seen as a classic example of the ethics of disclosure.
An elderly patient, both blind and deaf, is suspected of having an acute heart attack but somehow the results of her ECG fall through the cracks. She dies after five days of unrelieved suffering. After her death, a junior doctor is asked to write the case summary:
Fishing in the pack of X-ray films for the reports, I caught the long strip of an electrocardiogram. It bore the date of admission. I had asked a nurse to do it as part of the routine workup but had not remembered to check the results. The textbook signs of an extensive acute myocardial infarction were plain even to my untrained eye.
I took the tracing to the senior consultant’s office. He cast a glance over it, then stared at me for two uncomfortably long seconds. “Making a fuss about this won’t bring her back,” he said. He tore off the old date and then in a firm hand wrote the current date under the patient’s name. “She has died of an acute myocardial infarction. But let this be a lesson to all of us.”
There are multiple moral lessons wrapped up in this story, not the least of which is the duty to be forthcoming – not only for the sake of the patient and family but also for the sake of learning from what goes wrong so that safer and better systems can be designed.
Fudging the medical record strikes at the heart of this imperative. No health care organization would condone tinkering with patient records, but the industry hasn’t exactly been transparent in acknowledging that this sometimes occurs. And to date there’s been little collective effort to be more responsive to patients and families when disputes arise over the veracity of the chart. All of this needs to change, and the sooner the better.