Actual Case History

I continued to go through the patient’s deposition, feeling that the plastic surgeon had conformed to the applicable standards of care. The deposition then referred to a page in the patient’s chart wherein which there was a drawing of the outline of a female body. Notations were present on it, and there was a handwritten note specifically stating how the patient really wanted to have such large (450 cc) implants. The patient was questioned about the handwritten note on the page, but stated she had never seen such a sheet or note before the deposition.

Then I recalled something from my review of the records sent to me by the patient’s attorney. I found the page in question, and to my amazement,there was no notation┬ásuch as was discussed in the deposition. In going through the materials sent to me, I managed to find two other such pages. One was in another plastic surgeon’s records, and the other at the end of the file in a section labeled “miscellaneous.” These pages, indeed, had the notation. Naturally, I was concerned.

I then wondered how the patient could forget receiving a 12 page document covering the augmentation mammoplasty. She had said, at her deposition, she would liked to have received such a document. This seemed to lend a little more credibility to her testimony, which was part of my jury selection services and witness preparation services.

In reviewing the document, provided in the physician’s records sent to me by the patient’s attorney, I noticed some fax numbers at the top of the first nine pages. I still do not know the significance of that. However, I carefully went over the signature page and that page, with the patient’s alleged signature, indicated she received the 12 page document on augmentation mammoplasty which was dated Nov. 92. However, on reviewing the copy of the document provided in the plastic surgeon’s records, the only date was Aug. 94. In other words, the patient allegedly signed a note indicating she had received a 12 page document dated Nov. 92, but the document in the chart was dated Aug. 94.

I consider it a breach in the standard of care to have a patient sign a document acknowledging receipt of materials dated with a specific date, but to provide the patient materials with a different date which would indicate a different document.

Now it was becoming clear that perhaps the patient didn’t have total amnesia. She may, in fact, have not received all of the materials and information alleged to have been given to her.

It was my opinion that the records appeared to have been altered. This was my position at my deposition. When asked about the standard of care concerning the patient, I indicated that everything seemed okay according to the records, but considering the page with the drawing having had a self serving handwritten notation on some copies, and not on others, and that the patient allegedly having signed a a signature page indicating she had received a particular document when, in fact, the document in the chart was not the one in question, it was my feeling that everything in the physician’s records were suspect and I could not believe them.

This case was settled with the defendant obtaining a 5 figure award.

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