Then, follow the insurer's instructions to the letter. What you say to a patient in this critical period before the suit is filed may profoundly influence the ultimate disposition. Worse, these statements may be admitted in court as evidence, where they are likely to appear to imply culpability. When patients request their records, provide them in a polite and friendly manner, avoiding the temptation to ask why they are wanted. Patients have a legal right to access their own records.
People also have the right to have their medical care analyzed.
When a provider interferes with these important rights, it can provoke trouble. Never make extraneous or personal comments in the records, and don't comment in the chart on care the patient may have received from others. If you find a problem with the patient's treatment plan, take it up with others involved or with hospital officials such as the chief of staff, but keep your opinions out of the chart. Document everything you do for the patient Don't alter records after the fact If there is a poor outcome, don't lie. Dr. Oppenheim is president and CEO of CoMEDco, Inc., a medical-legal consulting firm.