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Medical Records Frequently Altered in Nursing Home Neglect Cases

When you meet with a lawyer for a free consultation about your case, one of the first things that the attorney will consider are the avenues of proving each element of a possible Illinois nursing home neglect claim. Even if you are certain that mistakes were made which led to harm, the key component as far as the law is concerned is the available proof.

This can be challenging, because most material that might be used as evidence in a possible trial is in the hands of the defendants themselves–the recollections of the nursing home employees and the records that they maintain. The “discovery” process of the case is supposed to fix those inequalities by allowing each side to share information. That information sharing comes in the form of transferring documents (like patient records) and depositions, where each party is interviewed on the record about the situation.

But of course this also leads to one serious potential problem: the defendants changing the records to make themselves look better. For example, if a resident was supposed to receive medication on a set schedule, the caregivers can simply change the medical charts after the fact to indicate that the medication was actually given, even if it wasn’t. This obviously represents an egregious breach of trust and honesty, but lawyers working on these cases appreciate that such action are not beneath some owners and operators when faced with legal accountability.

Experience to Identify Fraudulent Records
Altered nursing records are sadly commonplace. That is why the most experienced attorneys are quite well-versed in using different techniques to root out this fraud when it exists. In many cases, identifying the problem requires comparing many different forms of documentation with each other to identify possible discrepancies. Many of these tips are spelled out in a book on the subject, Medical Legal Aspects of Medical Records, released in 2010.

For example,in the medication example above,employee records can be examined to determine if the nurse or aide that reportedly provided the medication on each occasion was actually scheduled to work at that time. In the hurry to alter records, some may do a sloppy job, faking the actions of an employee who was not even working. Similarly, billing records need to be examined to identify possible discrepancies. It may be a sign of altered records if the services billed to the insurance provider do not match with claimed care in patient charts.

It is also critical to understand possible documentation copying. If nurse’s records are copied in the natural course of business, there is a tendency to alter details at that time to make the nursing home conduct seem more favorable. Lawyers working on these cases must therefore be familiar with the policy’s documentation policy and indication that the records they receive that they are copies.

If your loved one was harmed by neglect or abuse in an Illinois nursing home, you need experienced legal professionals on your side to ensure accountability. It is important to act quickly to guarantee lawyers are able to obtain the necessary documentation needed to prove that proper caregiving steps were absent. Contact our office today to see if we can help.

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