Potential clients often assume I take everything at face value that is found in the medical record.
They even assume, sometimes, that records have been changed and that you cannot prove it.
GUESS WHAT..? Sometimes, you can prove it when records have been changed, falsified, etc.
Example 1 –
I had a case years ago where the medical records reflected (and I will never forget these dates) that Ms. Smith (no not her real name) was turned every two hours, fed, checked on and given medicine on Jan. 11, 12 and 13th at the nursing home.
How did we prove that was a falsified record?
Ms. Smith was actually at the hospital on Jan 11 and 12th and deceased by the 13th.
Example 2 –
A man, diabetic, pressure ulcers, hypertensive in the nursing home was diagnosed as a pressure ulcer risk. When I asked whether they evaluated him on admission, I was handed a two page pressure ulcer assessment. The assessment done by an LPN said that Mr. Smith (again, not his real name) had strong pedal pulses in his right and left foot.
How did we prove that was a falsified record?
The week before he was admitted to the nursing home Mr. Smith had his left foot and ankle amputated. Most likely he had no pedal pulse since he had no foot.
While I know that nurses get busy, and they sometimes chart before care is given etc., or without knowledge whether care was given, it is sometimes hard to prove that. We do however, look for the obvious issues and holes so that we can bring attention to the fact that nursing home records do not always reflect the actual care given to the patient.
And sometimes, just sometimes, we can find such terrible mistakes like the ones above, that we get to prove to the defendants, judge or jury that the records are NOT correct.