Post dating legal documents
Any changes should be made according to applicable regulations and guidelines, such as the general advice or policies published by your College.
Corrections or modifications should only be made to your own entries.
She wrote "depression" as her diagnosis in the medical record.
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.
Although supportive of the clinical care, the College found that it was unacceptable to change the record by "scratching out notes…because of a perceived aggressive patient." It found that "the notes made by the physician failed to adequately document the interaction between the parties." The College recognized that "there may be some patient interactions that result in emotional confrontations that may be challenging for the physician to manage.
If there was some resistance to the diagnosis of depression expressed by the patient during their discussion, the Committee would expect the physician to document this information, but would not expect the physician to alter the record to ‘placate' the patient." The Colleges and courts have emphasized the importance of medical records that are contemporaneous, are an accurate representation of events and are adequately maintained.
He threatened to report the physician to the College and demanded to amend his own medical record. The patient had another outburst, told the physician she was irresponsible and threatened repeatedly to report her to the College.
Finally, to placate the patient, the physician crossed out the word "depression" and wrote "I don't know what's wrong with the patient." The patient complained to the College about, among other things, the physician's modification of the record.