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Physician claims charts were doctored in the Medical Records System at the Hospital

Posted Mar 26 2009 3:53pm

This is an interesting story here with the doctor challenging the hospital and it sounds like all were perhaps not getting along well, but the part about the hospital allegedly changing any patient records is very strange.  It sounds like an electronic records system is in place, so the good old audit trails will tell the story.  Some companies and hospitals, to ensure that everyone is in fact honest have copies securely sent to an off premise location as well, so even if someone in IT even thought about tampering, the copies would show that too, kind of like audit trails for the the audit trails. image

The second part about the nurse’s notes and the location of the patient is also something unusual, and if the hospital had any RFID system, well that would take care of where the patient was located at the time in dispute.  The hospital did the right thing to bring in an outside agency to review the information and more than likely the data and audit trails in question.  BD  

VERNAL — A doctor barred from practicing medicine at Ashley Regional Medical Center since October claims patient records were falsified as part of an effort to force his departure.

Dr. Richard Thomas is suing the medical center, claiming its chief executive officer, Si Hutt, released confidential information about him that harmed his medical practice. Thomas' lawsuit also names Bruce Guyant, the regional director of physician recruiting for LifePoint Hospitals, the medical center's parent company, as a defendant.

Then in early October, Thomas claims, records for two of his surgical patients were falsified to reflect that he had been informed of their worsening medical conditions, when he maintains he had not. Both patients required additional surgery, and one had to be airlifted to the Wasatch Front for further treatment.

In one case, Thomas alleges, a nurse falsified entries in a patient's charts to make it appear that she had properly monitored the patient and alerted him "in a timely fashion to the patient's declining blood pressure and suspected blood loss."  "(The nurse's) chart notes also contain inconsistencies suggesting she was with the patient in the patient's room, when in fact (the patient) was in surgery," the lawsuit states.

Thomas said that after learning of the "deliberate misrepresentations and inconsistencies" in the patient's chart, he dictated his own note to document his care of the patient and his belief that the nurse had falsified her account. He claims that the hospital subsequently removed his note from the electronic medical record for several weeks before reinserting it into the patient's chart.

The medical center used an independent company to review Thomas' case, but the doctor maintains that the hospital did not provide the firm with his notes documenting his belief that patient charts had been falsified.

Deseret News | Physician claims charts were doctored

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