Visitor Question

Altered medical chart to cover negligent nursing care?

Submitted By: L (PA)

My husband had a stroke in the ECU (Extended Care Unit), which was not noted for over four hours. Despite hourly worsening symptoms, the nursing notes say “patient remained the same.” I filed a complaint with our Nursing Board, and they investigated twice, but found the RN did no wrong.

Shortly after this, we were informed that the chart was physically changed to cover this lack of proper care. I have spoken with hospital compliance officers and the director of risk management, but they keep giving me the run around.

My husband needs to know how this all happened, for his peace of mind and overall well being.

He was only 54 years old when this stroke happened, and he was given no treatments to try to prevent the stroke for over four hours!

Once the depth of the stroke was discovered in the ECU, when a different MD arrived on the scene, there are no further ECU nursing notes in the chart for another four hours. These hours of care are just missing.

This is the short form of the details of that night. Is there a case here for a violation or for medical malpractice? What else can I do about this? Thank you.

Disclaimer: Our response is not formal legal advice and does not create an attorney-client relationship. It is generic legal information based on the very limited information provided. Do not rely upon the information in our response, or anywhere else on this site, when deciding the proper course of a legal matter. Always get a personalized case review from a local attorney.


Dear L,

Your case appears serious. Medical malpractice claims should never be pursued by a non-lawyer (referred to as a “Pro Se” plaintiff). To determine whether or not medical malpractice occurred will require a detailed review of your husband’s medical charts.

It is very rare for a doctor, nurse, or hospital to admit to having committed medical malpractice. As a result, it is likely a lawsuit will need to be filed. In your husband’s case, his claim will likely be against the the doctor(s), the nurse, and the hospital itself.

To successfully pursue a malpractice lawsuit will require your attorney to engage in pre-trial discovery including, but not limited to, depositions, interrogatories, the subpoenaing of hospital records (referred to as “subpoenas duces tecum”), and more. These are all actions a pro se plaintiff can not accomplish on his or her own.

Go online and research local malpractice attorneys in your area. Many attorneys post their qualifications as well as cases they have successfully settled or won after a trial.

Fortunately, most medical malpractice attorneys do not charge for initial office consultations. Gather copies of all of your husband’s medical records and make several appointments with several attorneys. They will review the facts surrounding your husband’s medical care, and determine the viability of his claim.

The above is general information. Laws change frequently, and across jurisdictions. You should get a personalized case evaluation from a licensed attorney. Find a local attorney to give you a free case review here , or call (888) 647-2490.

Best of luck,

Published: August 12, 2014

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