Medical Records

Medical records and patient history cards are documents kept by medical and other health practitioners and hospitals which record the consultation and medical history of a patient.

Issues frequently arise regarding the preparation of medical records, patient history cards, consultation notes and so on. A detailed study of the questioned entries using microscopy, photoanalytical and electrostatic forensic document examination techniques often shows that suspect entries could not have been made as part of an ongoing contemporaneous record.

It is also sometimes possible to conclude that a particular entry could not have been made at the time claimed because of the observed physical interaction of other writings in the document.

Other issues may arise regarding substitution and/or addition of pages to the file.

FDS has had success in recovering and visualising faint and faded CTG traces and other medical instrumentation print outs.

Related case studies:

Altered medical record

A surgeon was defending a medical malpractice suit and produced three pages of patient medical records in support of his case that he had cautioned the plaintiff patient as to the risks associated with a proposed medical procedure. The warning appeared on page 2 of the notes.

Hospital patient history notes

A patient under care in hospital suffered complications which resulted in permanent health problems. There was a question raised as to the attention given to