When the authenticity of a medical chart and related forms comes into contest there are usually three questions that need to be answered. Have notations been added to an existing chart? Have new pages recently been added to the file? Has the entire chart been back-dated or rewritten?
There are several ways to address these questions. In our laboratory we can:
- compare the contested chart to other charts from the same time frame
- intra-compare various entries in a file to assess whether they are similar or different
- refer to manufacturers technical information in our databases respecting the materials (such as paper, ink, type-fonts, etc.) used to produce the document.
A number of analyses are conducted to determine if, and to what extent a medical record may have been altered or tampered with, including:
- infrared examination of inks and obliterated entries
- indentation and sequencing analysis of words, lines, or entire pages
- intersection analysis of overlapping writing
- inter-comparison of signatures, initials, or handwriting
- inter-comparison of the paper stock or pre-printed forms
- examination of incidental markings
- inspection of all dates
- analysis of legibility and the care taken to write the notes
- analysis of spacing and formatting characteristics, as well as layout of text.
Infrared and Thin Layer Chromatography Examination
In assessing whether or not a medical chart has been altered it may be necessary to determine:
- how many inks were used to write each appointment note
- how many pens were used to write the patient chart
- if obliterated writing can be deciphered.
Our document examiner begins with a variety of non-destructive tests for this purpose. The first is microscopic analysis to determine pen and ink type, as well as colour.
Because the unaided eye cannot differentiate between the dye components that make up a single colour, we will then conduct ink differentiation tests using a Video Spectral Comparator (VSC) under infrared (IR) and infrared luminescence (IRL) conditions to distinguish between same colour inks. Differences in the reflectant and luminescent components of the inks can be seen under infra-red excitation.
The examination of inks under IRL conditions relies on there being a component, or combination of components, present in the ink that absorbs incident light (excitation). This light, when re-emitted at a longer wavelength, produces luminescence. A VSC permits the observation of the emitted light in the infrared region.
The IR portion of the examination looks at the reaction of ink to irradiation with a specific wavelength of light in the infrared region. This reaction can be observed using the VSC.
These tests are often effective in deciphering additions, making obliterated entries visible, and in distinguishing between a series of entries.
It should be noted that the ink differentiation tests have the potential to distinguish between inks that appear visually similar. However, if the inks are not differentiated it cannot be concluded that they are the same. They might be the same ink, or they might be different inks that react in a similar way to the excitation. In the latter circumstance the inks must be chemically tested, using Thin Layer Chromatography (TLC), to determine whether or not they are the same.
TLC is an analytical technique that allows for the identification of the various dye components comprising ink entries. The questioned documents are photographed to provide a visual record of their condition prior to this analysis. These photographs can be provided upon request.
Microdisc samples of ink and paper are then removed from the questioned handwritten entries. These samples are placed in individual vials that are then subjected to a solvent application. Once the ink has dissolved in the solution these samples are applied to a TLC plate. This plate is developed in two solvent solutions; one to identify potential dating taggants, the second to identify the dye components.
Indented Impressions and Sequencing
When writing is executed on a piece of paper positioned on top of others, non-inked indentations or impressions of that writing are often left on the pages below. In our laboratory an Indentation Materializer (IMED) is used to provide a visual image and record of these impressions, which appear as dark lines on a transparency.
Indentations may be found that indicate one or more pages of a medical chart have been re-written or removed. Where visible and indented impressions intersect it may be possible to determine which entry was written first. This sequencing of intersections may indicate that the entries are out of order, suggesting that the information was added at a later date.
The above procedure has often provided conclusive results of interlineations (data added at a later date, often squeezed in), page substitutions, along with revealing original writings (pages) that have been removed from the file. This is a very effective technique in detecting altered medical records.
Intersections
Entries made on the same page in a medical chart may be dated by analysis of intersections - the areas where two or more pen lines cross. Our document examiner may be able to determine the order of writing, possibly proving that a particular word, sentence or paragraph was added at a later time.
Signatures, Initials or Handwriting
Signatures, initials, and all handwritten or printed entries will be inter-compared to determine authorship, and if there is more than one writer, to determine which entries were written by whom. This analysis might reveal that only the doctor's writing appears on a page that would usually have some information entered by a receptionist or nurse. Where an employee's writing appears in the medical file, checking the dates against that persons' shifts might prove that he or she was not at work when these notes were purportedly written. Determining the typical pattern of preparation is often key in discovering an altered medical record.
Paper and Pre-printed Forms
Another analysis that can be performed is the inter-comparison of the paper stock or pre-printed forms to determine if different types of paper or different forms have been used. This is particularly useful when inspecting products such as brand-name charting sheets.
Incidental Markings
Although folds, creases, staple holes, punch holes, paper clip marks, offset marks and adhesives are incidental to the medical record, they can be of evidential value. It may be possible to establish that pages have been added or removed based on discrepancies in the fastening device.
Appointment Dates
Each appointment date is examined microscopically to assess whether changes to the day, month or year have been made. Overwriting of the year – such as 1997 to 1995, and date – 10 to 21, can be an indication of page substitution or re-writing of the entire record.
Writing Legibility and Formatting
Each entry will be compared to the others in the chart to determine whether there are discrepancies with respect to greater legibility, care and formatting. If possible, the chart as a whole will be compared to, and contrasted with, other records by the same doctor.