Fraudulent addition to a medical record for the purposes of covering up an incident can be detected by current technology. Expert document examiners will need the original medical record in order to analyze it for tampering. This will enable them to detect differences in ink, look for indentations caused by writing on sheets above the questioned document, and perform chemical analysis of the document. There are clues used to detect altered records.
Clues to altered records:
writing crowded around existing entries
changes in slant, pressure
uniformity or other differences in handwriting
erasure or obliteration
use of different pens or typewriters to write one entry
misaligned typed notation, impressions or lack of impressions from writing instruments on the following pages
ink offsets or lack of offsets on the back side of the preceding page, and
additions on different dates written in the same ink, while original entries were written in different ink.
All health care professionals should be aware that falsification of medical records is grounds for criminal indictment.
Case In Point:
The evidence speaks when victims cannot
Altered Medical Records
In Memory of Arlene Berry 1958-2000
“Truth cannot live on a diet of secrets withering within entangled lies” H. Michael Sweeney
The Quest for Medical Truth
The Arlene Berry Death Coverup
These are the facts:
There are numerous material deficiencies in the related medical record of Arlene Berry which manifest a complete lack of internal consistency ranging from out of sequence records, from the physician s Critical Care note to the nurses Triage to obviously rewritten, altered and falsified medical records seen between N-1 and N-3 of the nurses notes, including the physician’s Lab Report, marked by error, inconsistency, omission, and contradiction that is consistent with telling lies, to the Ventilation Record seen at A-16 and A-17, presenting similarly.
The record at A-6, what I consider to be quite contradictory, documents a “history of metastatic lung cancer” while the record at OP-54 clearly documents “no metastasis” and “mediastinoscopy negative”.
The Ventillation record contains a self-serving entry, ie. “without adversities” relating to patient’s intubation procedure, which took place at 0325 hours on May 24th of 2000, while the record at A-17 documents patient being “suctioned for moderate amounts of coffee ground emesis” at 0330 hours, only five minutes later, which can suggest thoracic injury, or perhaps a severe gastrointestinal problem, or both. That the patient’s Heart Rate soared to 174 bpm during the intubation procedure should be borne in mind. I find this to be very significant in terms of iatrogenic injury.
An example of going a step further, requires a high index for suspicion of iatrogenic injury which may become more readily apparent after following a time course for events, “before and after” , which in this case is marked by hypotension preceded by evidence of hypertension and is evidenced by a documented blood pressure of 162/80 at 0220 hours followed by a lethal drop in blood pressure to 78/70 by 0235 hours that is a hallmark feature of orthostatic hypotension in which BP rises or falls significantly. Another example is a documented BP of 163/117 at 0320 hours that by 0352 hours dropped to 85/52, with much of the record presenting similarly.
N-4 and N-5 present with less than half a page of documentation that is consistent with deliberate omission, such as withholding information.
A-24 and A-25 of the record, what I take to be identical forms, appear to be misaligned when superimposed (one over the other) and held over a light. Further, the print sizes appear to be slightly different and both are marked “Page 1 of 1”, to rule out conformity and consistency. Further, A-14 shows a misaligned margin suggesting a split in the page, or perhaps a cut out, with A-13 and A-27 presenting similarly.
Many of the records contain write-overs, primarily with respect to date and time, suggesting that perhaps the authors were no longer oriented to date and time of events that is consistent with making changes at a later date.
According to the Certificate of Death Arlene Berry died on May 24th of 2000. According to her physician “she died several days later with numerous metastatic lesions to her brain”. However, the medical record for May 23rd and 24th of 2000 tells a very different story, suggestive of a known “resistant bacterium” of the Staph aureus variety with a sepsis-like picture that is consistent with a severe hospital acquired infection or a bacterial meningitis. Further examination of the record reveals evidence of “iatrogenic neglect” (doctor caused negligence) and outright incompetence on the part of the healthcare providers to say the least, that is consistent with substandard care.
There is a complete absence of record with respect to the patient’s blood pressure between 1845 hours on May 23rd and 0040 hours on May 24th of 2000. This can suggest either incompetence or deliberate omission and can also constitute evidence of substandard care. lA-26 of the record documents a BP (blood pressure) of 78/70 at 0235 hours, while N-5 documents a BP of 98/70 at the very same time suggestive of having been copied.
A-16 documents a BP of 163/117 at 0330 hours while N-3 documents a BP of 136/85 at the very same time. The same record documents a BP of 121/81 at 0400 hours, while N-2 documents a BP of 112/57 at the very same time that is also consistent with copious error.
A-24 documents a Heart Rate (HR) of 154 bpm at 0330, while the Ventilation Record documents a HR of 126 bpm at the very same time, a significant difference. The same record documents the mechanical charting of the patients vital signs commencing at 0315 hours on May 24th of 2000. It is interesting to note that the patient’s transfer to the ICU had not taken place until ten minutes later at 0325 hours. I would really like to know how they were able to proceed with the recording of the patient’s vital signs in her absence.
A-4 of the record, what I take to be a Trauma Legend, barely visible in the physician’s notes situated at the lower right hand side of that record there is an obliterated area suggesting a white-out or perhaps an erasure. This to me suggests that was was indeed trauma involved.
A-1 of the record documents “she had a left lung pneumonectomy back in October of 1999”, which is erroneous. A-17 documents the very same error with “removal of left lung in 99”, suggestive of having been copied. The bald truth is that the patient was last seen by the same physician who originally had misdiagnosed her in October of 1999 for which she had the lung removed on January 13th of 2000.
A-3 of the record, what I take to be the physician’s diagnostic chart is a total blank. From that record it seems clear that nothing was entered because nothing was done. The same record was filed out-of-sequence. The emergency record at A-4 was also filed out-of-sequence. Interestingly both of these records were dated using a rubber stamp that is consistent with backdating.
A-1 of the record documents “I was called in later that night because the patient had become obtunded”, while N-6 documents “no response to deep pain” as early as 0030 hours on May 23rd of 2000. N-4 of the record documents that Dr. Jordan was notified of patient condition at 0225 hours, while N-2 documents “attempts to pull away to painful stimuli” at 0400 hours on May 24th, one hour and thirty-five minutes later, after the time the physician claims he was called in. There can be no question that the doctor lied.
There is a complete absence of documentation with respect to the patients bowel routine and urinary elimination pattern for toileting as evidenced at N-10 of the record, with the very same information omitted at OP-53 of the record.
Caveat: There are two precautions on record for what I take to be a warning with respect to “resistant bacteria”. The precaution can be seen more visibly at N-9 of the record under the subheading for “INFECTION CONTROL PRECAUTIONS”, evidenced by a check mark in the box. Notably, the particulars with respect to type of resistant bacterium are omitted. A “resistant bacteria” denotes a very serious infection of the “super-bug” antibiotic resistant variety, usually hospital acquired.
In a letter to the College of Physicians and Surgeons of Ontario dated November 28, 2000, Dr. Jordan writes “discussed the situation with family members and a decision was made to intubate Ms. Berry”, while the Ambulance Call Report documents an unsigned physician order to withdraw life support from an obviously critically ill patient, as evidenced by an obscure and secretive 3.3 Code only to be found in the annals of internal medicine. In acting as aforesaid it seems clear that Dr. Jordan ordered her death.
The record at N-6 documents bilious vomit at 1915 hours following the patient’s admission, as evidenced by “emesis of >> 100 cc yellowish fluid” that is the hallmark of intestinal obstruction that by 0330 documents “moderate amounts of coffee ground emesis” that is consistent with upper gastrointestinal bleeding. Another record documents a “large bloody emesis of reddish brown”, and “orally thick secretions” suggestive of a more significant backup of intestinal material, while the Ambulance Call sheet at A-7 documents an “intracranial bleed” that is inconsistent with the hospital record as a whole. This infers a blatant attempt tp obfuscate the truth.
The record at A-8 and A-9 documents “Medi-Vac team were due to arrive at 0435”, while the Ambulance Call sheet documents the time of the call event for ”call received at 0620” hours, a significant difference.
There are several late dictations and I can count at least three two page documents, all of them questionable seen at A-1, A-2, A-6, A-7, A-8, and A-9, as evidenced by the times and dates upon which they were dictated and transcribed. One of them was dictated in June of 2000, and transcribed in July of 2000, some two months after the patient s death. lThe Cardiac Index falsely documents the patient’s age at “55 years”, she was only 41.
N-7 documents a “stable” condition. Yet the same record documents a complete withdrawal of life support from a critically ill patient as evidenced by a Code 3.3, including a Nature Code 0 that is consistent with No Care.
The Ambulance Call report also documents a “pale, dry and cool” condition that is consistent with clinical manifestations of adrenal insufficiency, or hypovolemic shock. Compare Shock Syndromes in which pallor and cold peripheries suggestive of vaso-constriction all point to circulatory failure.
The same record at N-7 documents pulses X 4 good; head and neck OK; chest OK; abdomen OK; pelvis OK; extremities OK. The “coffee ground emesis” (suggestive of old blood and gastric juices) including the “large bloody emesis of reddish brown” and “ orally thick secretions” (suggestive of a more significant backup from the intestinal tract) associated with abdominal bleeding documented elsewhere on the record were completely omitted from the ambulance call record and substituted for “intracranial bleed”.
According to Dr. Jordan “she was admitted by Dr. Spiller with symptoms suggestive of metastatic CA of the brain”. According to Dr. Spiller ”a question has been raised” with respect to metastatic cancer of the brain. According to the record she was admitted for “vomiting”. Vomiting is not a diagnosis, but rather a symptom of many causes. The buck-passer, let us agree, tries to pass the buck together with all the possible blame for not having the right answer.
Much of the record is illegible. Illegible writing is reckless writing suggestive of callousness, ie no quality in writing, no quality in care. It also explains why many medical records are rewritten, after the fact, but which also affords opportunity for malfeasance to those who would dare skew the record in order to save face.
No autopsy was done. A family request for a formal inquest into the denied. cause of the patient’s death was also denied
Worthy of mention is that there is absolutely nothing in the patient’s blood values to even remotely suggest metastatic cancer, although a leukomoid reaction is a distinct possibility. In fact , everything points to a severe undiagnosed and untreated hospital acquired infection with a sepsis-like picture suggestive of the Toxic Shock Syndrome or staphilococcal meningitis, including evidence of neuroleptic drug involvement.
From the record it seems clear that the healthcare providers failed miserably in their concerted efforts to obfuscate the truth. Not only did they act together, but together with malice and forethought and with intent to defraud the estate of the deceased of any lawful claim they may have had against them (the doctors and nurses) for their part in substandard care and civil wrongdoing. They unwittingly escalated their plot into a criminal conspiracy and criminal wrongdoing of all kinds by their own doings. Perhaps its time they all had their moral codes thoroughly overhauled.
Altered Medical Records
by meverett Wednesday, Aug. 03, 2005 at 6:38 AM
The following Supporting Information is available for this article:
LSU Law Center's
Medical and Public Health Law Site
Articles on Law, Science, and Engineering
Scientific Misconduct: Part 3 - Standards for Scientific Record Keeping
I found this site while trying to research the prevalence of falsified medical documents...
I have experienced the death of a loved one, my 2 year old son, and have discovered false and contradictory statements from the ambulance report, which logically explains the confusion and mis-diagnosis at the hospital where they did not treat my son based on his actual condition or a truthful account of events leading up to his arrival at the hospital.
I do not know how to go about reporting this injustice, as there seems to be nobody who is willing to investigate this. Although the sequence of events in the report is impossible and illogical, and directly related to our son's needless death, our lawyer advises against persuing a lawsuit because the possibility of a small and limited court award does not justify the vast expense involved in the legal process and the possible risk of financial loss in the event that the case is lost.
Detecting Tampering with Medical Records
Articles From IEEE Engineering in Medicine and Biology Magazine
View the medical record of Arlene Berry