Michael L. Robertson specializes in the forensic document examination of medical records. He is frequently retained by attorneys and private citizens, prior to and during civil litigation, for the purpose of conducting document analysis on medical records which are suspect of forgery and alterations. Forensic medical record analysis is very common in our practice of questioned document examination.
In 2000, I spoke with the annual convention of the Ohio Academy of Trial Lawyer's on the subject of questioned documents in medical malpractice cases. At that time, I was developing a specialized protocol for medical malpractice and negligence cases. Based on my experience, I learned that some of these cases are fragmented and that relevant information may be missed. The missing link was an investigative element wherein the investigation is approached with an objective fraud model.
This model incorporates an open hypothesis by working backwards chronologically from the patient event(s) which initiated the inquiry. All available documents from all sources related to the patient are indexed, analyzed and evaluated for consistency. As a part of this investigative process all documents are scanned into a database or a spreadsheet for future comparison or exhibition.
I have identified eighteen criteria, when thoroughly investigated and analyzed can identify potential fraud by the medical professional and their staff. This goes beyond the field of forensic questioned document examination and incorporates our experience as fraud investigators to identify inconsistencies, alterations and time lines regarding medical malpractice investigations. Some of the investigative protocol is outlined below.
In some cases, the patient’s medical record file does not tell the whole story. In one case there was a reference to a medical procedure on a certain date which was exculpatory for the practitioner. A review of the appointment schedule and medical billing record revealed that the patient did not have an appointment on that date.
Scanning all of the documents and medical records as a matter of procedure provides the plaintiff with the best available copies. As the case progresses, new information may develop based on depositions or other sources that have an impact on the documentation that was initially undetected.
Verifying the veracity of original medical documents is an important first step in analyzing the medical file. Color photo copies and/or scanned copies can be substituted for true originals with or without the intent of deception. An analysis of many elements in the original documents is conducted while the documents are in our possession. This analysis will include looking for erasures, examination of obliterated or corrected text, interlineations and inks. Later analysis may include proper use of syntax, verb tense, date and time sequences, changes in habitual formats and other factors. The original documents are also examined while in our possession to match staple holes, identify intended writings on the paper and inappropriate folds in the paper. An often overlooked tool is the comparison of multiple part forms. For example, do the entries on one part of the form coincide with the appropriate entries on distributed copies. Ancillary files and documents should be included in any evaluation. Appointment scheduling records, calendars, medical billing records, administrative and consultation files separate from, but related to, the patients medical file, communications and documents related to laboratories, radiological facilities, EMS and Fire response logs, ambulance patient transport records, referrals, prescriptions, rehabilitation and therapy centers, nursing homes, dentists and other medical professionals.
A medical malpractice case should be approached as objectively as any complex fraud investigation with the understanding that the nature and method of the fraud is usually not known. For example, one of our cases involved a handwritten note, dated in 2000, which was prepared by the patient's primary physician. This note was written on a pharmaceutical company's notepad bearing their advertising. The investigation revealed that the pharmaceutical note pads were distributed by the company to the doctors in 2001; therefore the note was a fraud.
In defense of medical practitioners, document examination and fraud investigation may determine that the evidence being utilized by the plaintiff has been misinterpreted. However, the primary role of the document examiner for the defense is (1) to review the report and documentation of the plaintiff's expert, (2) to validate the examiners credentials and (3) to develop a line of questioning of the opposing expert in the deposition and/or cross examination.
If you have any concerns regarding your particular case you may telephone our office for an initial consultation, or send a message to us via e-mail by using our Contact Us page.
