The Dark Side of Medicine: Writing Lies into the Medical Record

Resuming the topic of how the public views the practice of medicine, particularly issues that deal with the patient's medical record, I recently received the following e-mail from a visitor:


I was searching after reading my medical records and realizing that doctors lie on records via entering false information or excluding details. I was shocked to discover how records can be used to create the ‘truth’ rather than represent the truth. This knowledge has totally removed any faith I had in the medical community. It’s really creepy to fully grasp that doctors will do this. Even the specialist, who I completely trusted, left a detail off the OR records to protect a GP and must have allowed the GP to enter a false note in the records. There is no way the specialist would have missed the fact that the note was false. As a patient there isn’t a thing I can do to prove the records contain lies. I’m not even sure if it would matter if the lies were exposed because any group that functions like this is not going to change its ways from one complaint. It’s mind blowing to see the dark side of medicine and wonder how often records are used to protect doctors while causing great damage to the patient via loss of faith. Obviously the medical community has a major problem. The GP involved would likely suffer no negative feelings about lying but the specialist did not strike me as the type who could just lie and forget about it. Discovering that the medical community places value in ‘creating’ the truth over just telling the truth and letting the chips fall where they fall is disgusting.

Realistically, it is only rarely (really only as part of a court action or other legal documentation) that physicians are required to swear "the truth and only the truth" regarding what they have written in their patients' charts. The assumption is that what is written by the physician is the truth or at least is a faithful representation of what the physician knows about the patient in terms of history, physical examination, testing results, diagnosis and what the physician presented to the patient in terms of informed consent for treatment. The chart is not a novel but should be a clear documentation of the patient's care and therefore should be as accurate as clinically possible and truthful. To find a chart not meeting this standard should be highly discouraging to us all about the professional behavior. ..Maurice.