Below is a re-write of an article I wrote in a newsletter I created a couple years back. It describes the importance of forensic document examiners in detecting medical chart tampering. More and more, forensic document examiners' services are being utilized in medical malpractice cases.
An experienced forensic document examiner once testified that among the charts he had examined, about 70 % of them contained some form of fraud. According to the Nurse's Legal Handbook, 4th ed., by Springhouse, “Evidence of tampering can cause the record to be ruled inadmissible as evidence in court."
According to the American Board of Forensic Document Examiners (ABFDE), "The examination of questioned documents consist of the analysis and comparison of questioned handwriting, hand printing, typewriting, commercial printing, photocopies, papers, inks ... in order to establish the authenticity of the contested material, as well as the detection of alterations."
Forensic Document Examination is a highly specializ ed field. The most qualified examiners have been certified by the ABFDE, have professional memberships, have been published, and have had many years of on-the-job training, as well as maintaining continuing education credits.
FDE's can be of valuable assistance to attorneys. They can determine whether questioned documents were created all at the same time, or at a later date, and/or on a different machine. In the above noted case, the examiner was able to determine that virtually the entire chart had been re-created, long after the fact, and that key pages had been removed.
Aside from medical records, wills, life insurance applications, deeds, income tax records, time sheets, contracts, loan agreements, etc., can all be examined to determine authenticity or tampering.
Infrared photography tests can be used to identify differences in writing instruments even if they appear to be the same. In his book, Medical Records Review and Analysis, Charles C. Sharpe writes, “In infrared luminescence photography, certain inks are recorded as white against a black background. They produce a photograph a jury can easily interpret."
One thing we home health nurses were taught years ago, was to never use two different pens when writing our note within the same paragraph. No two pens will write alike, even if you would use two of the same type of Bic pens in the same color. This, of course, could lead to suspicions of document tampering.
X-rays can also be used to determine whether an entry has been obliterated by any type of correction fluid. We're never allowed to use any type of correction fluid on our notes.
Scientific Techniques
The Electrostatic Detection Apparatus (ESDA) will show latent impressions, or indentations, on underlying paper. This test can help determine when particular notes were originally written.
Before laptops and paperless charts, hospital charts were in big binders which were kept at the nurse’s desk. When we needed to chart, we would open the chart up to the latest entry and begin to write.
A patient's chart was usually written in ascending order from the first page, including the date and time of the patient's admission, underneath, then topped by each succeeding page, on up to the current date.
Each time we write in a chart, a duplicate imprint is left on the page underneath it. The examiners have machines, such as the ESDA, mentioned above, and the indentation materializer (IMED), which enable them to clearly see the impressions left by each page on the page underneath. The IMED can help determine whether any original pages are missing, whether notes have been squeezed in, or added at a later time.
Medical charts are spontaneously written in a specific way. In a medical malpractice case, a suggestion was made that a forensic document examiner's services be obtained to check out the physician's records, due to the suspicious nature of the documentation. Medical records are not supposed to read like answers to interrogatories. The FDE brought in to examine the chart, determined that the entire chart, minus one page, had been completely re-written.
When we try to remember chronological events, we often remember the most recent events first, and then work our memory back to the farthest event. That was the physician's first big mistake. In doing so, while he had re-written the chart, the impressions showed he had done so in reverse chronological order.
Instead of the first page underneath showing the admission date and the last page, on top, showing the most current date in the chart, it was reversed. The impressions showed that the admission page was written last and the most current dated page was written first. And each page in between was consistent with the reverse chronology imprints. In fact, it was shown that the physician basically just sat down and re-wrote the entire chart all in one sitting, using the same pen, and relying on his most recent memory to work his way back.
The other big mistake the physician made was to leave that one page in the chart. That one page was an original in which only one note had been documented by a receptionist. The note was regarding the plaintiff, who had called and requested a copy of the chart.
However, what the physician apparently didn't know was that that particular page would have had the imprints from the page originally on top of it, as well as leaving imprints on the page below it. What the examiner found, was that the one page left had the imprints from the preceding page that was originally in the chart - which immediately indicated that at least one page was missing. Then, when examining the page below, the imprints showed that later documentation had been added to that one page.
Original documents written on typewriters or computers can be examined to determine the manufacturer of the machine, as well as different fonts, typeface, impressions, etc. Paper can be identified through the original manufacturer, the date of manufacture, and through watermarks as well.
Most ink manufacturers participate in the federal program requiring an ink change every January 1st. This helps the examiner to identify a specific type of ink and when it was produced. Examiners can determine the types of ink by employing the use of microscopic analysis, including the use of chromatography, and the specific colors of ink, by using UV/IVR Spectral Comparator and the Video Spectral Comparator (VSC).
The VSC can be used to sort shredded paper and distinguish between the same color ink, as well as obliterations, alterations, and erasures. In the case mentioned above, it was determined that the physician in question had re-written the entire chart all at the same time, with the same pen, about 2 years after the fact.
As I stated before, we nurses were taught to never use different pens when writing a note. If I happen to run out of ink, I simply make a note to that effect, and document that a different pen is being used. That way, should a chart of mine ever be reviewed, there would be no cause for suspicion of tampering. It is suspicious if two different pens were used within the same paragraph. However, no one uses the same pen every single time, either; especially, not over a period of several months.
Scientific Techniques
- Infrared Reflective Photography
- Infrared Luminescence Photography
- X-rays
- Electrostatic Detection
- Stereomicroscopy
- Laser Technology
- Video Spectral Comparator (VSC)
- Chromatography
Xerox Trash
The photocopier can be examined for what's called, "Xerox trash", which consists of tiny little scratches and marks made each time the copier is used. If you take a sheet of copied paper, hold it up to the light, you can see all the tiny marks made by the copier.
Each time a copier is used, it will leave a different set of marks. According to a study reported in the Journal of Forensic Sciences (March, 2004), "An electrostatic detection device (EDD) provides forensic examiners with a nondestructive method to examine indentations on a document. In this work, an EDD is used to detect latent physical markings left on documents by printers and photocopiers.
Seventeen ink jet printers, 12 laser printers, and 3 photocopy machines were used to produce test documents. Physical markings were detectable in the large majority of the documents and were reproducible 100% of the time."
The testing of Xerox trash is very helpful in determining whether any pages have been altered, added, or removed. Needless to say, the physician in this particular case failed the Xerox trash test too.
Microscopy is used to examine staple holes, folds, and creases to see if any pages have been added or deleted. Computer experts can also utilize special software techniques to determine if computerized documents have been altered or destroyed.
And finally, handwriting, formatting, and legibility are also examined to determine if greater care was given certain notes. For example, if a person usually writes illegibly, in very short sentences, and suddenly, the writing is very neat or goes into great detail, this should send up a red flag to the reviewer.
An examiner or reviewer will also look for incorrectly changed dates or other material. There is a standard protocol for making changes or correcting errors. We draw a single line through the word(s), write "error" above it, and sign our name. Anything not corrected in the right way will draw suspicion.
Other things looked for are differences in signatures, added notes, back-dated notes, or blanks left on the page. Once finished writing, if there is a blank space left at the end of the page, we're supposed to draw a single line, at an angle, through the rest of the page.
That way, no one can add anything later. I once audited a chart, where the staff member had back-dated entries for the previous two months - explaining why she didn't do certain required actions - all in one note!
Signs of Tampering
- Long Narrations out of sequence
- Notes written without a patient's stamp
- Notes written in different color inks
- Additions squeezed into a narrative note
- Additions on the edge of a page
- Entries obliterated or changed
- Billing entries not reflecting actual orders/notes
- Lab entries not reflecting the physician's orders
- Pathology/diagnostic findings which don't support stated need for surgery/procedure
- Difference in writing style from previous notes
- Missing records
For more information, check out Forensic Document Examiners at: http://www.abdfe.org I hope readers have found this information helpful and enlightening.
Comments