DOES THE DOCTOR SIGN OFF PROGRESS NOTES OF AN ADMITTED PATIENT AT THE HOSPITAL ON THE SAME DAY THAT IT IS WRITTEN?

I HAVE MEDICAL RECORDS FROM WHEN MY DAUGHTER WAS ADMITTED IN THE HOSPITAL THAT WERE SIGNED OFF ELECTRONICALLY AFTER SHE WAS DECEASED

Asked on June 1, 2009 under Accident Law, Arizona

Answers:

M.H., Member, California Bar / M.H., Member, California Bar

Answered 11 years ago | Contributor

Although the practice may vary from state to state, or even from hospital to hospital, it is not unusual for a physician to sign a note, especially a computerized note, after the fact.  You would need to see the facility's policies and procedures (of the Department of Medicine) to learn if this practice is appropriate or not. The P and P's may not even specify.  In such an instance the only way you would learn if the note was accurate (or, for example, altered to suit the physician's version of events after the fact) would be to take their deposition under oath about the circumstances surrounding the note.  Good luck.

I apologize for any inconvenience, I removed the second paragraph as it does not apply to your situation.  

I offer this information in an effort to allow you to better understand some general legal principals that may apply to your fact scenario.  This is not intended to substitute for a detailed consultation with an attorney admitted to practice before the bar of your state.  Laws differ from state to state.  Thus, the information above does not constitute legal advice.  Further, ethical rules prohibit an attorney such as myself from "practicing" law in any state but the state in which I am admitted.  


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