Falsified medical records resulted in a medical malpractice suit in Delaware, during which it was revealed that the defendant physician as well as her physician's assistant altered medical records concerning a four-day-old infant to make it appear that they had not been negligent in their failure to diagnose the infant for jaundice. While jaundice rarely results in serious complications, in this case the infant developed Kernicterus which resulted in permanent brain damage.
What is Jaundice?
Jaundice is a yellow discoloration of the skin and eyes in an infact, which occurs "because the baby’s blood contains an excess of bilirubin, a yellow-colored pigment of red blood cells." Jaundice is common in preterm babies and breast-fed babies in some cases. "Infant jaundice usually occurs because a baby’s liver isn’t mature enough to get rid of bilirubin in the bloodstream. In some cases, an underlying disease may cause jaundice," according to Mayo Clinic. In rare instances, jaundice can result in serious complications, and permanent brain damage, as in this case.
Falsified Medical Records
The child’s parents brought him to the defendant physician’s medical practice on July 21, 2006. The physician’s assistant observed a "yellow tint face/abdomen" and wrote this in the medical record for the visit. Two days later, the mother called the physician's assistant to tell her about an increase in the yellow tint. He was brought to the hospital that day, diagnosed with Kernicterus, and suffered "permanent brain and neurological damage."
The next day, July 24, 2006, the defendant physician informed her assistant about the infant’s condition. They had a conversation, and the assistant then replaced the note she had originally written with a new one that said "that the baby’s yellow tint was limited to his face and sternum, rather than extending to his abdomen as the original note had stated."
At trial, the existence of the replacement note was originally unknown to the plaintiffs. The attorneys for the defendants (one for the physician and one for her assistant) did know about the replacement note, but did not inform the plaintiffs attorneys. The existence of the note later became known, after which the assistant said that she had made a second note to clarify her observations after a meeting with the physician, and that the original note was merely a draft. The plaintiffs then alleged that the defendants had been allowed to perjure themselves at trial and lie about the existence of a replacement note. The Superior Court made a ruling concerning these allegations in February.