ER physician “doctors” patient’s chart

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Our client was a 24 year old single mother who presented to the Emergency Room of an area hospital complaining of sudden chest pain and difficulty breathing. The technician in triage did the right thing and performed an EKG to record the electrical activity of the patient’s heart. She also performed blood work, along with a special test called a “cardiac enzyme” test.

The EKG revealed “ST segment elevations” which means the patient was having a heart attack. Further, the cardiac enzymes in the blood were also significantly elevated, which provided additional proof that the patient was having a heart attack.pen and paper

At her deposition, the attending doctor who next saw the patient tried to deny that the elevated cardiac enzymes meant that the patient was having a heart attack.  She did agree that the elevated enzymes could indicate a heart attack, but she tried to wiggle out of it by saying the result could also be elevated from some other type of injury such as in a patient who “falls down and is on the ground for a long time”.

The doctor’s testimony became even more bizarre when I questioned her about the EKG.  I admit, EKG tracings are difficult to read unless you really know what you’re doing.  But when I asked her if she was capable of reading them, she said that she was fully capable.  I also asked her if an “ST segment elevation” on an EKG is indicative of a heart-attack, and she agreed with me.  But when I asked this doctor whether the tracings showed an ST segment elevation, she denied it and insisted that the tracings were normal.

I found her denial to be very helpful in demonstrating that she committed gross malpractice.  The reason it was helpful is because this particular EKG machine generated a written interpretation, in plain english, on the second page.  And in fact, the plain english diagnosis of the tracing was “ST segment elevation” indicative of a heart attack – which was confirmed by our own expert.

The Attempted Cover-up:

And yet, this doctor still wasn’t ready to be truthful with me even after I confronted her with the computer printout.  So after some further questioning, it was revealed that the doctor had “doctored” our client’s medical records. You see, after this physician completed her cursory examination of our client, she wrote down her diagnosis in the chart.  But after our client was left waiting over 4 hours to be admitted to the medical unit, she suffered a massive heart attack and died.  

As it turns out, this doctor then went back to the patient’s chart and re-wrote the chart to try to cover up the malpractice.

 

Defendant "doctored" the chart

Actual Note (click)

Originally the note read:

(1)  Pneumonia

(2)  ESR (end stage renal disease)

(3)  Admit to medical unit

…but then she changed it to read:

(1)   Chest Pain, Rule Out Heart-Attack

(2)  Pneumonia

(3)  ESR

(4)   Admit to Heart Unit

 

Unfortunately, I see this kind of thing all the time.  It’s bad enough that she killed this woman who left behind a little baby.  But did she really have to go and change the patient’s chart to try and cover up her mistake?  Does this make anyone else angry?

6 comments on “ER physician “doctors” patient’s chart”

  1. Jane L. Stone says:

    Anthony, Another fantastic job by you uncovering and proving outrageous conduct and complete lack of concern by a member of the medical profession. This is a very sad story and yes it makes me angry too. Jane Stone, Esq.

    • Thank you for your reply. I’ve seen many changed records over the years, and they always remind me of the very first time I ever saw it in a case involving a severely brain damaged child. I had just started working as an associate with several of the top medical malpractice attorneys in New York. The firm asked me to attend a court conference in Manhattan. When I got there, one of defense lawyers started making a big fuss about the fact that we hadn’t yet provided them with a copy of their own client’s records. I just “felt” something was odd about this. Why would a defense lawyer want a copy of his own client’s records – when he already has possession of the originals? So I went back to the office and literally scoured the entire chart, line by line, until I discovered why they were asking for it. The version of the records that we obtained before the lawsuit was started was altered by the defendant after she learned of the lawsuit. So I ended up with 2 different versions of the chart. The lesson I learned from that experience is that whenever a defense lawyer asks me to provide a copy of their own records, it often means that their client confessed to them that they changed the records to coverup their malpractice.

  2. DC, MD says:

    Anthony, this case is another example of why all my patients that have misjustice, will be given your number by me. As a physician in medicine over 30-years, I am as sick as you when it comes to defendants covering up their mistakes. Maybe this hourly doctor was at the end of her shift, or just maybe she/he did not want to work or do her job. Thanks again for protecting the regular New Yorkers out there trying to get the best out of their insurance bucks.

  3. joanne bieder, RN says:

    Of course this story makes you angry. You have to wonder why.
    why was there a delay in treatment ?
    why did the healthcare provider do what he/ she do?
    Very sad outcome.
    Joanne Bieder, Rn,CNRN,CLNC
    Legal Nurse Consultant

    • Thanks for your comments. We may never know ‘why’ but we do know it wasn’t right. The ER doc testified that, in her experience, the longest she’s ever seen anyone sit in the medical unit’s waiting area was one hour. In this case the patient was there over 4 hours.

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