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HC 260 Week 5 Focus Topic

The copies of the charts were given and no changes

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tumor biopsied. The copies of the charts were given and no changes were made on Makleys charts but of Figgies he had marked out certain things and handwritten in new information saying that Moskovits did refuse to do a biopsy. The holding was that the evidence regarding the physician’s alteration of the patient’s records supported an award of punitive damages, regardless of whether the alteration caused actual harm. Entries in a patient’s medical record should be made using a computer and should be accurate and complete. If a system is set up correctly different physicians can pull a patients records and make notes when needed and it can be documented correctly. Changes to medical records should be made in my opinion with one physician adding in the changes in the computer record, stating the date and time of the change, keeping the original information as well, the reason for the change, the physician making the change and the physician witnessing the change. “The contents of a medical record must not be tampered with once an entry is made; therefore, the record should be used wisely” (Pozgar, p. 283).
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