Scribble Notes: Court Imposes Punitive Damages, Notes Destroyed In Expectation Of A Lawsuit.

Scribble Notes: Court Imposes Punitive Damages, Notes Destroyed In Expectation Of A Lawsuit.

Legal Eagle Eye Newsletter for the Nursing Profession

February 2018

Alteration or destruction of any medical record, including handwritten scribble notes that are not part of the formal chart, when litigation is in progress or has been threatened, is a very serious matter for any healthcare professional. NEW YORK SUPREME COURT APPELLATE DIVISION January 17, 2018

The child’s pediatrician referred her to an endocrinologist for an evaluation of the child’s high blood glucose levels. The endocrinologist saw the child three times in her office. The child had to be sent home from school by the school nurse due to vomiting and a stomach ache. The parents could not get her into the pediatrician so they took her to an emergency room. The child died in the hospital from diabetic ketoacidosis. The family’s lawsuit alleged malpractice by the endocrinologist in failing to diagnose and treat Type I diabetes, leading to the child’s death.

When the endocrinologist got a letter from the family’s attorney she threw out the handwritten "scribble notes" she jotted down during two of the child’s visits. The New York Supreme Court, Appellate Division, approved $1,200,000 in punitive damages for the endocrinologist’s act of throwing away her handwritten notes that she had used in dictating her office-visit reports for the patient’s chart. Once litigation has been started or has been threatened no healthcare professional is permitted to alter or destroy pertinent evidence. Gomez v. Cabatic, __ N.Y.S.3d __, 2018 WL 444195 (N.Y. App., January 17, 2018).