HIM 520 Module 6 Ethics Short Paper Example

The Note That Cannot Be Rewritten: An Ethics Case on Record Integrity After a Patient Fall

[Student Name]

Southern New Hampshire University

HIM 520: Leading as a HIM Professional

Module Six Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

The Note That Cannot Be Rewritten: An Ethics Case on Record Integrity After a Patient Fall

On a Tuesday morning, an 81-year-old patient at Sycamore Bend Health's acquired hospital got out of bed alone at night, fell and fractured her hip. The next afternoon, her attending physician called the health information director. His note from the day before the fall did not mention fall risk, although he said he had discussed it with the nurse. He asked whether the director could edit the note, or have the vendor change it, so that it included a fall risk assessment dated the day it was written. He was worried about a lawsuit. This paper analyzes the request and the director's response.

Alteration Versus Late Entry

Health records can be changed legitimately, but only in ways that are transparent. A late entry adds information that was not documented at the time, clearly labeled as late, with the date and time it was actually written and the author's identification, and ideally a reason. An amendment or correction fixes an error while keeping the original visible. What the physician asked for was different: a change that would make it appear that the assessment had been documented before the fall. That is alteration of the record, and it misrepresents what was known and recorded at the time care was given.

Why Alteration Would Also Fail

Even setting ethics aside, alteration would likely be discovered. Electronic records keep audit logs that record who viewed or changed what and when. Adler-Milstein et al. (2020) describe these logs as a detailed record of user activity that researchers increasingly use to study how clinicians work, and the same detail is available in litigation. An edit made after the fall, backdated or not, would appear in the log, and a record shown to have been altered after an adverse event can do far more damage in court than an honest gap in documentation. Deliberately altering or destroying relevant records can also expose the organization and the individual to sanctions for spoliation of evidence and to professional discipline.

Ethical Principles at Stake

Four principles apply. Honesty requires that the record reflect what actually happened and when. Nonmaleficence, the duty not to harm, applies because a falsified record could mislead the clinicians who care for the patient next and could harm her ability to learn what happened. Justice concerns fairness to the patient and her family, who have a right to an accurate account if they seek one. And fidelity to the profession requires health information professionals to protect the integrity of the record even when colleagues they respect ask otherwise. The AHIMA Code of Ethics expects members to stay out of unethical practices and not to hide them, a standard that fits this request exactly.

Understanding the Physician's Fear

The physician is not a bad actor; he is afraid. In the closed-claim sample studied by Studdert et al. (2006), claims lacking an error mostly ended without payment, which suggests that an honest record showing reasonable care is better protection than a doctored one. His fear also points toward a more constructive path. Gallagher et al. (2007) reviewed the case for disclosing harmful errors to patients and described how honest communication, including an explanation and an apology when appropriate, can support patients and may reduce the anger that leads to litigation. Mazor et al. (2004) reviewed research on communicating with patients about errors and found that patients consistently want to be told, although evidence on how disclosure affects lawsuits was limited. Whether or not an error occurred, the path forward runs through honesty.

What the Nurse's Note Shows

One more fact changed the picture. The nurse caring for the patient on the night before the fall had documented a fall risk score, bed alarm activation and a conversation with the physician about the patient's confusion. The record therefore already contained evidence that fall risk had been assessed and discussed, just not in the physician's note. Had the physician's note been altered, it would have created an inconsistency with the nurse's timestamped entries and with the audit log, undermining the credibility of the entire record, including the parts that showed good care. An honest late entry that refers to the nurse's documentation would strengthen that record rather than weaken it.

The Director's Response

The director declined the request, calmly and without accusation, and explained why an edit would be both wrong and visible in the audit log. The director then offered what was allowed: if the physician had in fact discussed fall risk with the nurse, he could write a late entry today, clearly labeled with today's date and time, describing what he recalled and when the conversation took place. The director also recommended that the physician contact risk management, which handles potential claims and can guide communication with the patient and family, and noted that the hospital's disclosure policy supports clinicians through that conversation. Because the physician had asked for an alteration, the director documented the conversation in a confidential memo to the compliance officer, following policy, and placed a preservation hold on the patient's record.

Supporting the Physician and Fixing the System

Declining the request does not end the director's responsibility. The case revealed that the acquired hospital's physician note template has no fall risk field, while the flagship's does, a gap left over from the merger. The director will raise this with the documentation committee so that fall risk appears in the template, and will ask risk management to include the case, without names, in education on late entries and disclosure. A physician who feels supported is more likely to come forward honestly next time.

Conclusion

The request to change the note tested whether the record would stay truthful under pressure. The ethical answer and the practical answer were the same: the record must show what was known and written at the time, with any later information added openly as a late entry. By refusing alteration, offering legitimate options, involving risk management and compliance and fixing the template gap, the director protected the patient, the physician and the hospital.

References

Adler-Milstein, J., Adelman, J. S., Tai-Seale, M., Patel, V. L., & Dymek, C. (2020). EHR audit logs: A new goldmine for health services research? Journal of Biomedical Informatics, 101, Article 103343. https://doi.org/10.1016/j.jbi.2019.103343

Gallagher, T. H., Studdert, D., & Levinson, W. (2007). Disclosing harmful medical errors to patients. New England Journal of Medicine, 356(26), 2713-2719. https://doi.org/10.1056/NEJMra070568

Mazor, K. M., Simon, S. R., & Gurwitz, J. H. (2004). Communicating with patients about medical errors: A review of the literature. Archives of Internal Medicine, 164(15), 1690-1697. https://doi.org/10.1001/archinte.164.15.1690

Studdert, D. M., Mello, M. M., Gawande, A. A., Gandhi, T. K., Kachalia, A., Yoon, C., Puopolo, A. L., & Brennan, T. A. (2006). Claims, errors, and compensation payments in medical malpractice litigation. New England Journal of Medicine, 354(19), 2024-2033. https://doi.org/10.1056/NEJMsa054479