Post dating legal documents
Although the College was satisfied with the care provided, it found the method by which the changes were made to the record was not acceptable, despite the physician's intention to make the chart complete and accurate.In emphasizing the need to sign and date any changes to medical records, the College stated, "While the Committee is not concerned that these changes to the chart were made for any improper purposes, nevertheless, because of the serious consequences that unattributed changes to medical records can have, the Committee will caution [the physician] with respect to changing medical records after the fact, and to ensure that, in future, he and/or his staff sign and date such changes." The physician was therefore criticized not for refusing to complete the form but rather for making the changes to the medical record in an inappropriate manner.A 50-year-old man presented to a locum physician complaining of generalized aches and pains, reduced appetite, and headache.He also had a history of depression and was under the care of a psychiatrist.A few weeks later, the patient complained to the College about several aspects of the physician's care.In the course of the College's investigation, the patient's copy of the medical record was compared with the doctor's copy, and the addition, the word "today," was discovered.Sometime later, the physician added the word ‘today' to the medical record of the first encounter to confirm the timing of the initial injury.
Questions concerning whether a medical record was contemporaneous or modified arise from time to time in the course of proceedings before the courts and the Colleges.
Feeling intimidated, the physician authorized modified work duties for a period of two weeks.
Unable to reach his family physician, the patient returned six days later asking the physician to extend the disability period.
It may be necessary to modify an existing medical record at the time of an entry or later for a variety of reasons.
For example, upon review of a clinical note you dictated, you may discover an obvious error in the transcription.
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