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Spoliation of medical records

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eMediNexus    26 December 2022

Medical records are the basis of medical malpractice claims as they can prove or disprove the allegation of medical negligence. Spoliation of medical records is negligent, reckless, and intentional destruction of evidence.1 The DGHS guidelines, vide letter No. 10-3/68-MH dated 31/8/1968, as under, should be followed to prevent spoliation.2

 

  • When correcting an error, strike out the incorrect statement with a single line and place your initial and date next to it. Then make the correct entry in the record. Attempting to obliterate the erroneous entry by applying a whitener or scratching through the entry in such a way that a person cannot determine what was originally written raises the suspicion of someone looking for negligent or inappropriate care.
  • Entries in a medical record should be made on every line. Skipping lines leaves room for tampering the record, a practice not in the best interest of the patient or provider.
  • In medico-legal cases, the record should be in the custody of the doctor who examines the patient and finalizes the report. No one else should have access to it.
  • Correcting of personal identification of data of the patient like: name, father/ husband name, age, sex, address should only be done the basis of affidavit by notary or 1st class magistrate.

 

References

 

  1. Wolfson LH. Spoliation of medical records: negligent, reckless, and intentional destruction of evidence. QRC Advis. 1999;15(8):8-12.
  2. Singh S, Sinha US, Sharma NK.  Preservation of medical records- an essential part of health care delivery. Indian Internet Journal of Forensic Medicine & Toxicology 2005;3(4).

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