TAMPERING ALERT SIGNALS:

·         Records are MISSING.

·         An Incident or event is NOT documented in the record.

·         Record conflicts with Victims testimony.

·         Different inks were used.

·         Entries that should be by 1 provider show different handwriting.

·         Copies of the record from different sources reveal differences.

·         Late entries or entries out of sequence.

·         Additions are squeezed in or obviously added later

·         Additional pages added after the record completed.

·         Evidence of substitution.

·         Records show erasures, obliterations or scratch-outs.

·         Destruction of original records

·         Major discrepancies in documentation patterns.

·         Notes were dictated weeks or months after the fact.

·         Suspicious entries.

There are a lot of ways that the medical record could have been tampered with and every medical record reviewed should be checked for evidence of tampering.

If tampering is suspected it may require a forensic document examiner or an Electronic Medical Record (EMR) expert.