How easy is it for doctors to alter or delete their "chart notes"?

[Dan Williamson]

Jurisdiction

Indiana

During the start/midst of the pandemic (April, 2020), the doctor in charge of my wife's wound care (during my mentally-incapacitated wife's hospital-stay for clipping of a bleeding, duodenal ulcer) performed a debridement to the pressure wound in her sacral (tailbone) region - without my permission (IE, I did NOT sign the blanket "Consent-to-treat" form). He has denied doing it but she came home with obvious surgery from it - which resulted in her progression from a Stage 2 pressure wound to a Stage 4 - completely open to the bone and muscle - wound!

 

[Zigner]

During the start/midst of the pandemic (April, 2020), the doctor in charge of my wife's wound care (during my mentally-incapacitated wife's hospital-stay for clipping of a bleeding, duodenal ulcer) performed a debridement to the pressure wound in her sacral (tailbone) region - without my permission (IE, I did NOT sign the blanket "Consent-to-treat" form). He has denied doing it but she came home with obvious surgery from it - which resulted in her progression from a Stage 2 pressure wound to a Stage 4 - completely open to the bone and muscle - wound!

Have you gotten your wife to another doctor for a professional opinion on this matter?

 

[zddoodah]

While your post might raise a legal issue, your question does not, and I'm not sure how any answer (which obviously will not be specific to the doctor in question) could possibly be of any value to you.

If you want to pursue a medical malpractice claim, consult with a local attorney.

 

[Dan Williamson]

Her CNP (and an RN) both viewed the damage (first full week of May, 2020). Their assessment was, "Medical Assault". In trying to pursue charges (via a prosecutor), I was told to file a police report. Trouble is...in that jurisdiction... the hospital has its OWN police dept and any and all "charges" have to go VIA their "Patient Advocate dept"!
The doctor AND the Patient Advocate dept BOTH denied that a "debridement" (to my wife's Sacral-area-wound) had occurred (in the last week of April, 2020) during my wife's stay at their facility. She was delivered to our home that following Sunday (May 3rd) by the SAME hospital's EMS service with a (2 cm dia.) Sacral-region-hole (surgically removed - clear through ALL layers of skin) with only an ABD pad to cover it and NO other formal dressings (commonly used to keep a wound of this nature infection-free). I took time-stamped pics of the wound...within 1 hour of her arrival at home. We then had to deal with the (Stage 4) damage (over 8 months of "HELL"!) and we FINALLY were able to get it healed (Jan, 2021). During the last month of the Sacral-area-wound's healing time, a different, related wound occurred (as a result of the months it took healing the "Sacral-area" pressure wound).
Just recently (August, 2021) during a visit to our LOCAL wound clinic, (to our GREAT surprise) this same doctor was on call there and (after checking this new, now-infected pressure wound) got "in my face" (less than 6") about the first wound!! He AGAIN denied the (April, 2020) "debridement" saying, "I don't have chart notes on it! So, THEREFORE...I didn't do it!"

 

[Zigner]

Your best bet would to consult with a local attorney, as suggested above.

 

[army judge]

He has denied doing it but she came home with obvious surgery from it - which resulted in her progression from a Stage 2 pressure wound to a Stage 4 - completely open to the bone and muscle - wound!

As a licensed osteopathic physician and an attorney myself you do yourself no favors by making public pronouncements that you can't prove.

Yes, physicians can "amend" chart notes.
I've done it when necessary, especially in surgery or ER.
Those notes are also transcribed and transcriptionists DO make errors or mistakes during transcription.

Be very careful ACCUSING anyone unless you're in possession of THE smoking gun.

 

[cbg]

My physician father died four years ago so Army can correct me if I'm wrong, but as I recall amending chart notes is one thing; deleting them is quite another and can cost the physician his license.

 

[army judge]

My physician father died four years ago so Army can correct me if I'm wrong, but as I recall amending chart notes is one thing; deleting them is quite another and can cost the physician his license.

No need to correct you, as recall correctly. The complete deletion of such records becomes problematic for the provider.

Here's a more scholarly retort about such matters.

Patient Documentation Dos and Don'ts for Doctors and Nurses