It is common, when speaking with a potential client, to have the client express concerns about the health care providers altering or changing the records to cover up negligent care. Most medical negligence attorneys have seen that on a few occasions, but usually not very often. My response to potential clients is, basically, “let’s hope they do that, because it makes it a much stronger case.”

Medical liability insurers routinely advise their insureds to never alter or change a record. Addendums or supplement information can be inserted, but they always should be labeled and dated. One malpractice carrier has taken the position that a physician who alters records violates the insurance contract and would jeopardize the insurance coverage.

In the “old days,” before the advent of electronic records, we would sometimes look carefully at hand-written records to see if something didn’t look right. Insertion of a line or two that seemed to be squeezed in, or the ink doesn’t look quite the same. In a few cases, “document examiners” were hired who can analyze the inks used for different entries or do a microscopic examination of the paper to see if an entry was made at a date other than indicated.

Electronic health records, which are now used almost universally in hospitals and larger clinic settings, have changed this. Now the issue becomes whether analysis of the electronic entries show that changes were made. The electronic records allow an attorney to obtain an “audit trail” which will show every time a provider logged into the system, and whether any changes were made. This is an increasingly complex setting in which “document examiners” are no longer relevant, but computer and electronic data specialists are in great demand to analyze the electronic records.