Ask a Business Lawyer. Get Business Law Questions Answered ASAP.
Uggh! I think I made a fool of myself.
I referenced this article:
Making Changes in Charts Do's and Don'ts of Documentation
By Joan Roedigerand and Patricia Salmon,
Obermayer Rebmann Maxwell & Hippel LLP
February 1, 2005, Physician's Practice, Vol. 15, No.3
The fact that a record may contain something that is incorrect or that may have legal implications does not justify destroying, rewriting, or replacing the prior record. Doing so places the credibility of the entire record in jeopardy.
The only time it is appropriate to destroy and rewrite a medical record entry is when an error is recognized when it is being written and before the entry has been completed. For instance, if you are in the middle of a patient exam and you realize you wrote the wrong name on the progress note, you can properly dispose of the incorrect progress note and start over.
DISCLAIMER: Answers from Experts on JustAnswer are not substitutes for the advice of an attorney. JustAnswer is a public forum and questions and responses are not private or confidential or protected by the attorney-client privilege. The Expert above is not your attorney, and the response above is not legal advice. You should not read this response to propose specific action or address specific circumstances, but only to give you a sense of general principles of law that might affect the situation you describe. Application of these general principles to particular circumstances must be done by a lawyer who has spoken with you in confidence, learned all relevant information, and explored various options. Before acting on these general principles, you should hire a lawyer licensed to practice law in the jurisdiction to which your question pertains.
The responses above are from individual Experts, not JustAnswer. The site and services are provided “as is”. To view the verified credential of an Expert, click on the “Verified” symbol in the Expert’s profile. This site is not for emergency questions which should be directed immediately by telephone or in-person to qualified professionals. Please carefully read the Terms of Service (last updated February 8, 2012).