GP deregistered after altering clinical records

Doctors whose care or conduct is called into question may be tempted to try to amend records to conceal or justify an error. This is always a mistake. Regulators take falsifying records and other deception extremely seriously. This case, involving a GP who was deregistered over deceptive conduct including altering medical records, highlights the potential consequences.

Alleged missed diagnosis and medical records

Dr L was investigated over two complaints of failure to properly carry out skin checks. Both patients had consulted Dr L for skin cancer checks and both claimed Dr L’s examinations appeared brief and cursory. He had not examined them fully even though both patients had expressed concern about skin cancer risk. Both patients claimed he provided no or minimal information about follow up.

In both cases, the patients consulted other doctors after seeing Dr L and both required surgery to treat skin cancers.

When Dr L was advised of the complaints by the regulator he submitted clinical notes, which were quite detailed and differed considerably from the patients’ versions. Further investigation revealed that the original, very brief notes, had been deleted from the record system and replaced with longer comprehensive notes. The software showed the notes, which purported to be contemporaneous records, had actually been created after the patients complained.

In both cases evidence from the practice management system and expert opinion suggested that the consultations were too short for a thorough skin check to have occurred. The tribunal found the clinical care inadequate and that it constituted unsatisfactory professional conduct.

Dr L’s conduct in deleting the original notes, recreating them and presenting them to the regulator as the contemporaneous record was dishonest and inconsistent with him being a fit and proper person to hold registration. The tribunal found his actions in falsifying clinical records constituted professional misconduct.

Additionally, Dr L faced professional misconduct charges on two further cases. These cases had both elements of sexual boundary violations as well as falsification of medical records.

Dr L’s conduct constituted professional misconduct and unsatisfactory professional conduct.

The tribunal found that, considered separately, the boundary violation, inadequate examinations or failure to make proper notes would not warrant de-registration. While serious, individually those issues could be dealt with by imposing conditions of further training and mentoring. However the deliberate attempts at deception by falsifying medical records, motivated by protecting his own interests, made Dr L unfit to hold registration. The tribunal was not convinced Dr L was genuinely remorseful or likely to conduct himself ethically if faced with a similar conflict between his own interests and the public interest.

Dr L’s registration was cancelled and he was disqualified from reapplying for a total of three years, including the 15 months he was already suspended. He was ordered to pay the regulator’s legal costs.

Never amend records for your own benefit; for example to cover up a clinical error or professional boundary breach. Always act ethically in your dealing with the regulator or Medical Board.

If you need to amend a medical record you can add a further entry, for example to include new information that has since come to light, but do not change your original contemporaneous note.

Avant factsheet – Medical records: the essentials

Avant article – Here’s the right way to correct medical records

Avant podcast – Making changes to a medical record

For medico-legal advice, please contact us on nca@avant.org.au or call 1800 128 268, 24/7 in emergencies.