Tampering with the Electronic Medical Record (Or Not)

The electronic medical record (EMR) is becoming omnipresent in the healthcare system. But EMR tampering issues in medical-related cases are a brand new frontier. It’s rare for Certified Legal Nurse Consultants and attorneys to peek behind the EMR curtain, but in the case of Samuel Sweet versus UPMC University Hospital we get to do just that. I first ran across this case last year, when the judge ordered the trial delayed after a local newspaper article about the case and the alleged tampering was published just before jury selection.

What makes the case notable was the plaintiff attorney’s identification of possible tampering with the EMR. The plaintiff alleged that a physician altered the EMR to place a “Difficult Airway” display tag on the patient’s record three days after the patient died. Post-incident documentation like this is what I refer to as a CYA (“Cover Your Actions”) entry. The plaintiff attorney filed a motion to amend the complaint requesting punitive damages related to the alteration of the EMR claiming a cover-up. The hospital responded that the alteration was part of the QA process. The judge sided with the hospital and refused the amendment.

While this issue will not have its day in court, legal nurse consultants have the opportunity to fully explore one of the first EMR tampering allegations in a case, as well as study a court record in a medical malpractice case. You can read the pleadings, discovery and motions by following this link (enter GD-09-019407 in the case number field) and make a decision for yourself about the case and alleged tampering. I already know what I think.

This case is a must read for any CLNC® consultant interested in EMR tampering issues.

Success Is Inside!

P.S. Comment and share what you think about the case.

2 thoughts on “Tampering with the Electronic Medical Record (Or Not)

  1. Being a nurse who has not set foot in a hospital in many years, I can totally see how easy it would be to alter the EMR. I had a case where the surgeon drew a picture to the mother explaining what happened but it was never in the EMR! Needless to say, the case never went forward. How sad! Carry on all you great nurses!

  2. I was told it was very hard to tamper with EMR. There were alarms and everything, but he able to and was protected by the hospital. Glad the family won but so sad this cost her the life of her husband.

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*The opinions and statements made by Vickie Milazzo, the founder of Medical-Legal Consulting Institute, Inc. are based on her experiences and expertise, should not be applied beyond the specific context provided, and do not guaranty or project actual results. Vickie Milazzo is no longer involved in the operations or management of the business, but is involved as an independent education consultant.

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