Can a Physician Be Assessed Punitive Damages for Altering or Destroying Medical Records?

During her testimony, Dr E was asked about the notes in the chart, and she was forced to admit that she transcribed the scribble notes into the patient's record after the patient died and she had been contacted by the plaintiff's law firm asking for the records.

This month we look at the interesting question of whether a plaintiff in a malpractice lawsuit against a clinician may recover punitive damages when the clinician destroys or changes medical records in an attempt to avoid malpractice liability.

The case involved a 6-year old girl, Miss C, whose mother took her to a new pediatrician, Dr P, in mid-October. The pediatrician recommended that Miss C see a pediatric endocrinologist because the child’s blood sugar level was high. The girl’s mother asked Dr P for a referral and the pediatrician recommended Dr E.

Dr E, the endocrinologist, worked from a private office in the basement of her home. Her sister served as her office manager, and her two nephews helped with billing and appointment scheduling. The office was low-tech, and Dr E had a habit of using what she called “scribble notes” during exams and then typing the notes into the medical record at some later point in time.

Dr E saw the patient a total of 3 times – in late October, in mid-November, and in mid-December. Meanwhile, the patient’s pediatrician also saw her again in late November, and then early January.

The endocrinologist concluded that the child was obese and developing type 2 diabetes. At the conclusion of the mid-December office visit, the child’s mother was given an appointment card for an appointment two months later, in mid-February.

Tragically, the child never made that appointment. In late January, Miss C came home from school complaining of lethargy and that she wasn’t feeling well. She brought home a note from the school nurse describing her symptoms. That evening the child had a stomachache and vomited. The next day, the mother tried to have the child seen by the pediatrician, but she was not available, so the mother took Miss C to the hospital. The child remained in the hospital until her death, 3 days later. 

The final autopsy report revealed the cause of death to be attributable to “bilateral cerebellar tonsillar herniation secondary to cerebral edema following diabetic ketoacidosis.”