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Myth 5: Physicians are allowed to “cor- rect” past entries in medical records af- ter an unexpected outcome or notice of claim.


Truth: It is never acceptable to alter or correct a medical record after you are notified of a claim. Upon reviewing the medical record


when served with a notice of claim, you may be tempted to add information that you believe will assist in your defense. Resist this temptation. Plaintiff’s attor- neys will try to use this information to discredit you, suggesting that you did something wrong and are trying to con- ceal it.


The TMLT claim staff recommends


that you place the medical record in a secure location to protect the authen- ticity and avoid any temptation to alter information. Absent a notice of claim, it is appropriate to make a late entry or ad- dendum in the medical record, but only with proper identification and the reason for the delayed entry. “The entry should be clearly labeled as


‘late entry’ or ‘addendum’ with the date the addendum was completed and the date to which it relates,” Ms. Mills said.


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“ ‘Correcting’ the medical record without clearly indicating that you are doing so is considered altering the medical record, and altering the medical record seriously jeopardizes your credibility and poten- tially your defense. While there may be no breach of the standard of care, record alterations are difficult to defend at trial and can result in settlements.”


Myth 6: You can rely on patients to re- port an accurate and complete medical history.


Truth: For a number of reasons, patients are often poor historians of their medical information. They may not know what is important to share. They may not under- stand their condition or the seriousness of it. They may not remember the details or may be embarrassed or reluctant to share their health information. Consider the following to help you obtain more accurate medical histories:


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• Make it easy for patients to update their medical history forms. Send these to patients in advance or make them available on your website. Pa- tients may provide more accurate in- formation if allowed to complete the forms before an appointment.


• Ask patients to bring all of their medi- cations when they visit your office.


• Ask patients to list any other treating physicians on their medical history forms.


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• When discussing a patient’s medical history, ask open-ended questions, e.g., What has changed in your medi- cal history since your last visit? Pa- tients who are not questioned thor- oughly may leave out details.


• If details of the patient’s history are 14 TEXAS MEDICINE September 2013


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