Mcare Act Update
We want to remind you that Section 511 of the Medical Care Availability and Reduction of Error (Mcare) Act passed in 2002 sets forth the appropriate manner for making corrections to a patient’s medical record in Pennsylvania. It also establishes that it is unprofessional conduct to make alterations to a record or to otherwise eliminate information in a record that would give rise to a professional liability action.
The Mcare Act sets forth that entries in patients’ charts are to be made contemporaneously or as soon as practicable to the activity being recorded. With regard to corrections to the record, the law states that it is not considered unprofessional conduct to:
(1) Correct information on a patient’s chart where information has been entered erroneously or where it is necessary to clarify entries made on the chart, provided that such corrections or additions shall be clearly identified as subsequent entries by a date and time.
(2) Add information to a patient’s chart where it was not available at the time the record was first created, provided that:
(i) Such additions shall be clearly dated as subsequent entries.
(ii) A health care provider may add supplemental information within a reasonable time.
With regard to supplemental information, it is probably best to not add information to a chart if it does not add to the patient’s ongoing treatment. For example, it will likely do very little to supplement a record with additional information after it is learned that a patient died. A plaintiffs’ attorney will argue that, even if properly dated and timed, the supplemental information in the record is self-serving and designed solely to assist the health care provider’s defense in a subsequent professional liability claim.
In addition to a potential professional licensing violation, the Mcare Act also allows a court, if it finds that there has been an intentional alteration or destruction of medical records, to instruct a jury as to an adverse interest, meaning that the jury can infer that the information contained in the altered record is not true. In short, it means that the health care provider will lose the malpractice action and then will likely face licensure sanctions by the appropriate State Board.