Altered Medical Records, Lose the Case: Part I

Altering medical records is no laughing matter, and for doctors involved in medical malpractice suits, it could mean the kiss of death. Take, for example, a New York jury who recently awarded $2.1 million to a man who suffered a life-altering stroke after his doctor engaged in some "altering" of the man's medical records. What appeared to be an open and shut case for the defense, turned out to be something drastically different at second glance.

The plaintiff in the case, Gaetano Bongiovanni said that his longtime internist, Dr. Nader Attia, had failed to prescribe anti-hypertensive drugs after he complained of severe headaches, resulting in a severe stroke. The stroke led to loss of body control, an inability to speak, and significant cognitive defect. Although he has improved somewhat, he now walks with a cane, can't work or live alone and is unable to work. The defense's case rested on the argument that Gaetano had only been to see Dr. Attia two times between the time of his first complaint and his stroke. However, Gaetano said that he had been to visit his doctor five times during that time period. Although computerized scheduling records showed that Gaetano had canceled two of the five appointments, one of the cancellations was clearly fraudulent as their was a prescription in the system made the same day as the "canceled appointment".

Indeed, other damning evidence showed that an earlier chest X-ray revealed borderline cardiomegaly, which would suggest that hypertension was affecting Gaetano's heart. However, Dr. Attia insisted that the patient did not present with signs or symptoms of hypertension and that he merely had conjunctivitis. However, one week before the stroke, Gaetano's blood pressure was 190/110 and at the time of the stroke it was 218/110.

I have seen all too often in my review of medical charts for medical malpractice cases what appear to be "altered" records by doctors and "altered" medical charts by hospitals. This is not a white lie and in Michigan, it's a felony. I am not talking about an addendum, rather information added, deleted or changed after the fact. Simply put, that is bad medicine folks.