How long to keep original anesthesia records after scanning?

[aneftp]

Obviously the move towards electronic medical records is increasing. However many of us are still caught in hybrid situations (depending on facilities we are covering).

How long do you or your facilities keep the original anesthesia records even after they have been scanned.

State laws require anywhere between 5-9 years of medical record keeping. But many are unclear about "original records" compared to "electronically copied records".

The reason this is important is I just took a risk management online course with MedPro (my malpractice claim carrier).

The malpractice claim company recommended to keep the original records for as long as state laws require even if those records are scanned.


Why? Because (although it doesn't happen often). Physicians have been known and caught changing the medical records even with the same ink. But attorneys have ink experts who can do forensic test to determine how old the ink is and whether the ink that was on the paper was on day 1 or modified with another ink used on day 2 (after a sentinel event happens). If records are scanned, there is no way to use forensic testing.

What is everyone's take?

I have seen some of my peers rewrite the entire anesthesia pre op and intra op record after an OR event to "make it look" clean. There are some that modify records as well. It happens. We all know that. Fortunately it probably doesn't happen often....but we seen newsletters from our state medical boards reprimand state boards.

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[pgg]

Why? Because (although it doesn't happen often). Physicians have been known and caught changing the medical records even with the same ink. But attorneys have ink experts who can do forensic test to determine how old the ink is and whether the ink that was on the paper was on day 1 or modified with another ink used on day 2 (after a sentinel event happens). If records are scanned, there is no way to use forensic testing.

How does the plaintiff's inability to use some technique to try to prove record falsification hurt the defense's case?

They might as well say "well, we think you murdered a hooker in Vegas that afternoon too, but we can't prove it, but we think you did, and that shows the jury you're a bad person" ...

What a bunch of crap.

Obviously I'm not a lawyer, do what your lawyer and malpractice carrier tells you to do.

 

[aneftp]

How does the plaintiff's inability to use some technique to try to prove record falsification hurt the defense's case?

They might as well say "well, we think you murdered a hooker in Vegas that afternoon too, but we can't prove it, but we think you did, and that shows the jury you're a bad person" ...

What a bunch of crap.

Obviously I'm not a lawyer, do what your lawyer and malpractice carrier tells you to do.

There have been documented malpractice cases where physicians have been caught altering the original medical record.

Plaintiffs hire forensic ink specialists to determine if documents have been altered or "added". They can actually determine in great detail how old the ink is on the paper.

Unless you scan the records in immediately after dropping off the patient, there is no way to tell if you altered the records and if it's thrown away.

It's a mess with hybrid electronic records these days. Most hospitals I have worked at have kept records per state laws even after making scans.

 

[pgg]

There have been documented malpractice cases where physicians have been caught altering the original medical record.

Plaintiffs hire forensic ink specialists to determine if documents have been altered or "added". They can actually determine in great detail how old the ink is on the paper.

Unless you scan the records in immediately after dropping off the patient, there is no way to tell if you altered the records and if it's thrown away.

It's a mess with hybrid electronic records these days. Most hospitals I have worked at have kept records per state laws even after making scans.

I get all that. Key words: "where physicians have been caught" ...

My point is simply this, the plaintiff can allege anything they want, but if they have no evidence, so what? The burden is on them to prove that kind of egregious criminal misconduct.

 

[aneftp]

I get all that. Key words: "where physicians have been caught" ...

My point is simply this, the plaintiff can allege anything they want, but if they have no evidence, so what? The burden is on them to prove that kind of egregious criminal misconduct.

Let me tell you this. At a hospital I used to work at. Malpractice case back in 2004 (from sentinel event that occurred with taking a patient off Plavix back in 2000 (remember Plavix was still new and not many details about when how many days to take the patients off Plavix before surgery and time between stenting to take Plavix off).

Anesthesiologist was sued. Case went to trial. Plantiffs pointed to cardiologist note that patient was a high risk. So why did anesthesiologist proceed with elective procedure? Guess what happened? Anesthesiologist is anal about everythig. He was sure there was no such note written.

Turns out (cardiology had already settled case before trial). Turns out cardiologist had altered note. Cardiologist had written the extra note in after the sentiel event (patient was in hospital was 30 plus days before expiring). Ink expert testified that the ink was from a different pen source. Cardiologist denied it.

Doctors will try to cover their actions especially with adverse events. Who knows when he added the note in to try to point fingers at the anesthesiologist. I have seen surgeons dictate reports trying to point the fingers at anesthesiologists whenever there is even the smallest of hypoxemia.

Things happen. People get desperate. There would be no way to defend yourself in this case if original medical records had been destroyed.

So in this case, the defenant (not the plantiff) had to prove that the records were altered. They did not pursue charges against the cardiologist. It wasn't worth the trouble for the courts.

 

[Random Anesthesiologist]

Let me tell you this. At a hospital I used to work at. Malpractice case back in 2004 (from sentinel event that occurred with taking a patient off Plavix back in 2000 (remember Plavix was still new and not many details about when how many days to take the patients off Plavix before surgery and time between stenting to take Plavix off).

Anesthesiologist was sued. Case went to trial. Plantiffs pointed to cardiologist note that patient was a high risk. So why did anesthesiologist proceed with elective procedure? Guess what happened? Anesthesiologist is anal about everythig. He was sure there was no such note written.

Turns out (cardiology had already settled case before trial). Turns out cardiologist had altered note. Cardiologist had written the extra note in after the sentiel event (patient was in hospital was 30 plus days before expiring). Ink expert testified that the ink was from a different pen source. Cardiologist denied it.

Doctors will try to cover their actions especially with adverse events. Who knows when he added the note in to try to point fingers at the anesthesiologist. I have seen surgeons dictate reports trying to point the fingers at anesthesiologists whenever there is even the smallest of hypoxemia.

Things happen. People get desperate. There would be no way to defend yourself in this case if original medical records had been destroyed.

So in this case, the defenant (not the plantiff) had to prove that the records were altered. They did not pursue charges against the cardiologist. It wasn't worth the trouble for the courts.

Do you mean the cardiologist tried to pass the amended note off as the anesthesiologists? If so, I wonder if there could be a civil suit filed by the anesthesiologist.

That's horrible.