Post dating legal documents
Feeling intimidated, the physician authorized modified work duties for a period of two weeks.
Unable to reach his family physician, the patient returned six days later asking the physician to extend the disability period.
It may be necessary to modify an existing medical record at the time of an entry or later for a variety of reasons.
For example, upon review of a clinical note you dictated, you may discover an obvious error in the transcription.
He threatened to report the physician to the College and demanded to amend his own medical record. The patient had another outburst, told the physician she was irresponsible and threatened repeatedly to report her to the College.
Finally, to placate the patient, the physician crossed out the word "depression" and wrote "I don't know what's wrong with the patient." The patient complained to the College about, among other things, the physician's modification of the record.
A record appropriately created at the time of the encounter and properly maintained contributes greatly to the successful defence of a lawsuit, or in responding adequately to a complaint to a regulatory authority (College).
Sometime later, the physician added the word ‘today' to the medical record of the first encounter to confirm the timing of the initial injury.
He wanted the patient's medical record to be accurate should the workers' compensation agency question the worker's entitlement to benefits and request precise details concerning the date of the injury.
A review of these CMPA cases from 2003–2007 indicate that the most common issues arising from the modification of medical records were: A 35-year-old male truck driver presented to a walk-in clinic complaining of back pain after having fallen from his truck earlier that day.
On physical examination, there was tenderness of the lumbo-sacral spine, and limited range of motion in all directions. The physician prescribed analgesics and recommended follow up with the patient's own family physician and also a referral to a physiotherapist.