Alterations, Additions & Rewritings of Medical and Business Records

Alterations, Additions & Rewritings of Medical and Business Records

Lawyers are interested in the forensic examination of disputed records for three main reasons: Case value, avoiding client perjury, and due diligence to the client. Many attorneys are aware that Forensic Document Examiners can determine the authenticity of a signature and do various examinations on typewriters (see below) and printed documents. However; many attorneys are not aware of examinations to detect additions, alterations, or rewritings.
Our laboratory can:
1. Detect an alteration made with a different pen, albeit a color matched ink.
2. Determine the age of a document.
3. Determine the age of a particular ink.
4. Determine when an ink was first commercially available.
5. Determine if additions, alterations, or rewritings of records have occurred, when it happened, who did it, and what pages were replaced.

In a case regarding the record tampering issue to be deemed significant, an addition to a record should have at least one of the following criteria:
1. The intentional concealment of a change that is not clearly noted but takes instrumentation to detect.
2. An addition or change to a critical entry.
3. An entry that was not made contemporaneously with the other entries with no notation of late charting.
4. A pattern of alterations to the critical entries.
5. Testimony is different than the forensic evidence present.
6. The whiting-out, scribbling out or obliteration of an entry.
7. The removal of pages from the records, or expanding the chart with pages created after the fact.

Additions that are made with a color matched ink can usually be detected by the use of an infra-red image converter or possibly an argon or krypton laser. The difference in the ink in this range of light is caused by the different excitation levels in the inks. If the inks are different, one ink may luminesce while the other will not and filters out. This can be captured photographically and makes an excellent court exhibit as shown in figures A through C below, or on closed circuit video.
This is especially important when the questioned entry is the lynch-pin entry in a case. Some signs to look for that may indicate record tampering: 1. Crowded entries. 2. Entries compressed around other entries. 3. Entries made in the margins or along the bottom of the page. 4. Slant, pressure, and uniformity of handwriting. 5. Relative length of questioned entries to other entries in the chart. 6. Unnatural spacing between entries. 7. Entries that shift the blame onto the patient such as pt. refused or non compliant. 8. Differences between what the client says and what the records indicate. 9. Strange notations such as complained of NO chest pain.
We also have the ability to chemically or optically remove obliterating inks, stamps, white out, or factors blocking the reading of a particular entry.