HCA 315 Module 6 The Medical Record as a Legal Document Example

If It Was Not Documented: The Medical Record as a Legal Document

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Health Care Administration Program, Aspen University

HCA 315: Legal Aspects of Health Care Administration

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Month Day, Year

If It Was Not Documented: The Medical Record as a Legal Document

The medical record serves care, billing and quality, but in a lawsuit it becomes the central piece of evidence. Juries often trust the record more than anyone's memory years later. A record that is complete, timely and honestly corrected protects patients and providers; a record that has been altered can turn a defensible case into a lost one. This paper examines the record's legal role and works through a correction scenario.

Why the Record Is Evidence

Courts generally treat records made in the regular course of business, at or near the time of the events, by people with knowledge, as reliable enough to admit as evidence. Medical records usually meet this test. Their reliability depends on being made promptly and kept without tampering. Late or altered entries weaken that reliability.

Authorship and Authentication

Every entry must identify its author and the date and time it was made. Electronic records do this automatically through logins and time stamps; paper records rely on signatures and dates. Entries made by one person for another, such as scribes, must identify both. Shared logins undermine authentication and are prohibited.

Corrections Versus Alterations

Mistakes happen, and correcting them is proper. Altering a record to change its meaning after the fact, especially after an adverse event or a lawsuit, is improper and can be illegal. The table contrasts the two.

A Correction Scenario

An 84-year-old composite patient fell in a clinic hallway after a vaccine visit. The nurse's note, written hurriedly, said the patient was steady on leaving the room. That evening, after hearing that the family was upset, the nurse wanted to rewrite the note to add that she had offered a wheelchair, which she believed she had done. The office manager advised her to add a clearly labeled late entry that evening, with the current date and time, describing what she recalled and noting that it was written after the fall, and not to change the original.

Why the Distinction Matters

Electronic records keep audit trails showing every view, entry and change. In litigation, audit trails are often requested, and an entry made after an incident but disguised as contemporaneous is easily exposed. Once a jury believes a record was altered, it may disbelieve everything else in it. A transparent late entry, by contrast, is understandable and credible.

Copied Text as a Legal Risk

Copy-and-paste creates a different problem: entries that claim examinations or findings that did not occur at that visit. In a study of 167,076 records, copied examinations appeared in about 3% of all exams and 25% of patient charts, and 13% of authors had copied at least one exam (Thielke et al., 2007). A more recent analysis found half of all note text duplicated from earlier text (Steinkamp et al., 2022). In court, a copied exam that includes findings the clinician could not have seen undermines the whole record.

Patient-Identified Errors

Patients who read their notes often find mistakes; about one in five readers in a large open notes survey believed they had spotted a mistake, and many of those judged it serious (Bell et al., 2020). Handling these through the formal amendment process, with addenda rather than silent edits, keeps the record accurate and legally sound.

Retention and Legal Holds

Retention periods come from state statutes and payer contracts. When litigation is reasonably anticipated, a legal hold suspends normal destruction for relevant records, including emails and audit logs. Destroying records under a hold, even under a routine schedule, can lead to court sanctions for spoliation of evidence.

Subpoenas and E-Discovery

Records requested by subpoena or through discovery must be produced according to legal requirements and privacy rules. Electronic discovery may include metadata, audit trails and messages. The practice routes all legal requests to its privacy officer and attorney and produces records in a consistent, documented way.

Documentation Habits That Protect

Good documentation is timely, factual, objective and complete. It records what was observed and done, patient statements in quotation marks where important, communications with other clinicians and instructions given to the patient. It avoids blame, speculation and criticism of colleagues. After an incident, clinicians document facts, not conclusions about fault.

The Administrative Role

Administrators set policies on late entries, addenda, copying, scribes and retention; ensure audit trails are active; train staff; and manage legal holds and requests. They also make sure incident reports, which are usually kept separate from the medical record for quality improvement, are handled according to state law.

Records After an Incident

After an adverse event, clinicians should document facts promptly and objectively, avoid speculation about fault and not refer to incident reports in the medical record. The incident report goes to risk management under the practice's quality process. Mixing the two can make protected quality documents discoverable in some states.

Who Owns the Record

The physical or electronic record belongs to the provider or organization, but patients have legal rights to access and copy the information in it. This distinction matters when a physician leaves a practice or a practice closes: records must remain available to patients and successors for the required retention period.

Paper and Hybrid Records

Many organizations still hold some paper records alongside electronic ones. The same principles apply: entries are dated and signed, errors are corrected with a single line and initials, and pages are never removed. When paper documents are scanned, the scanned copy becomes part of the legal record, and the practice's policy states when originals may be destroyed.

Conclusion

The medical record is legal evidence whose value depends on being timely, authenticated and honestly maintained. Corrections are proper when transparent and improper when they disguise changes, as the fall scenario shows. Copied text and unaddressed errors weaken records, while legal holds and careful production protect them in litigation. Documentation habits formed every day decide how a record will look in court years later.

References

Bell, S. K., Delbanco, T., Elmore, J. G., Fitzgerald, P. S., Fossa, A., Harcourt, K., Leveille, S. G., Payne, T. H., Stametz, R. A., Walker, J., & DesRoches, C. M. (2020). Frequency and types of patient-reported errors in electronic health record ambulatory care notes. JAMA Network Open, 3(6), Article e205867. https://doi.org/10.1001/jamanetworkopen.2020.5867

Steinkamp, J., Kantrowitz, J. J., & Airan-Javia, S. (2022). Prevalence and sources of duplicate information in the electronic medical record. JAMA Network Open, 5(9), Article e2233348. https://doi.org/10.1001/jamanetworkopen.2022.33348

Thielke, S., Hammond, K., & Helbig, S. (2007). Copying and pasting of examinations within the electronic medical record. International Journal of Medical Informatics, 76(Suppl. 1), S122-S128. https://doi.org/10.1016/j.ijmedinf.2006.06.004