Why would a hospital delete Medical Records?

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My hospital deleted incriminating medical records after being notified of the malpractice lawsuit

“Doctors and hospitals often employ deny and defend strategies, acting with a sense of impunity to avoid accountability for their mistakes. This approach disregards ethical standards, legal obligations, and the resulting harm to patients.” – See deny and defend presentation

There are no legitimate or ethical reasons for a surgeon or hospital to delete medical records, including those detailing surgery, time-out procedures, and operating room personnel, after being notified of a malpractice lawsuit. In fact, doing so is illegal and unethical. Medical records serve as a crucial component of patient care continuity, legal documentation, and a record of the care provided. Here are some reasons why maintaining these records is essential and why their deletion would be problematic:

  1. Legal Obligation: Healthcare providers are legally required to maintain patient records for a specified period, often dictated by state laws. These records are critical for defending against malpractice claims, providing evidence of the care given.
  2. Ethical Standards: Medical ethics dictate that healthcare providers must act in the best interest of their patients, which includes maintaining accurate and complete medical records. Deleting records undermines patient trust and violates professional ethical standards.
  3. Patient Safety: Medical records are vital for patient safety, ensuring continuity of care and informing future healthcare providers about past medical history, procedures, and outcomes.
  4. Accountability: Medical records hold healthcare providers accountable for their actions and decisions. Erasing records after a malpractice lawsuit notification would suggest an attempt to evade responsibility or conceal evidence, which could have severe legal and professional consequences.
  5. Regulatory Compliance: Regulatory bodies require the retention of medical records to monitor healthcare quality and compliance with laws. Destruction of records can lead to regulatory penalties, loss of licensure, or accreditation.

In the context of a malpractice lawsuit, the preservation of medical records is even more critical. These records provide essential evidence that can clarify what happened during the care and treatment of the patient. Any attempt to alter or destroy medical records after being notified of a lawsuit not only complicates legal proceedings but also significantly undermines the defense’s credibility and can result in legal penalties, including sanctions and presumptions of guilt.

If there is suspicion or evidence that medical records were deleted or altered in the context of legal proceedings, it would likely trigger a serious legal inquiry, potential criminal charges, and professional disciplinary actions against those involved.

Upon learning of the malpractice lawsuit, Dr. Kesterson at the John Peter Smith (JPS) Hospital in Fort Worth deliberately erased the medical records detailing the surgery, including the identities of those present in the operating room, the documentation of the time-out procedure, and the description of the surgical procedure they believed they were conducting.

Reference: my-doctor-operated-on-the-wrong-vertebra-and-tried-to-conceal-it

Time-out Procedure used by Hospitals

The time-out procedure used by hospitals is a critical safety step in the surgical and procedural environment, designed to prevent errors such as wrong-site, wrong-procedure, and wrong-patient surgery. This procedure is part of the Universal Protocol, which was established by The Joint Commission and other authoritative bodies to enhance patient safety. The time-out is performed after the patient has been positioned for the procedure but before the procedure begins. Here’s a general overview of how the time-out procedure is typically conducted:

  1. Initiation: The time-out is initiated by a designated member of the surgical or procedural team. This person is responsible for ensuring that the time-out is conducted properly and that all steps are followed.
  2. Participation: All active members of the procedural team participate in the time-out. This includes surgeons, anesthesiologists, nurses, and any other personnel directly involved in the care of the patient during the procedure. Participation is mandatory, and all activities not related to the time-out must cease.
  3. Verification of Patient Identity: The team verifies the patient’s identity, often using two identifiers such as the patient’s name and date of birth. This step ensures that the team is performing the procedure on the correct patient.
  4. Confirmation of the Procedure and Site: The team confirms the procedure to be performed and, when applicable, the site of the procedure. For procedures involving laterality (left or right side), multiple structures (such as fingers or toes), or levels (such as spinal surgery), the exact site is confirmed and often marked on the patient’s body before the time-out.
  5. Review of Critical Information: The team reviews critical information that may affect the procedure. This includes any allergies the patient may have, the results of relevant tests, the availability of necessary equipment, and the need for antibiotic prophylaxis.
  6. Open Forum for Team Questions or Concerns**: The time-out provides an opportunity for any team member to express concerns or ask questions about the procedure. This step ensures that all team members are on the same page and that any uncertainties are addressed before the procedure starts.
  7. Documentation: The completion of the time-out procedure is documented in the patient’s medical record, including confirmation that all relevant steps were performed and that there were no unresolved questions or concerns.

The time-out procedure is a key component of patient safety initiatives and reflects a culture of safety within healthcare. By ensuring that all members of the team are focused and in agreement about the patient’s identity, the procedure, and the site, the time-out procedure helps to minimize the risk of preventable errors.

Reference:https://www.jointcommission.org/standards/universal-protocol/
The Universal Protocol provides guidance for health care professionals. It consists of three key steps: conducting a pre-procedure verification process, marking the procedure site, and performing a time-out.