IT'S ALL FREE! Redacting Documents

As a new legal nurse consultant, you may be responsible for redacting documents.  As a nurse, you know that there's a correct way to note errors in medical records which includes, in part,  drawing a single line through the entry. The purpose of the single line is so that the entry isn't obliterated and can still be read. On the other hand, a redacted document is one that has had parts of it obliterated so that those parts can't be read.

Redaction means to edit a document, usually to remove information. In medical malpractice litigation, redaction is often used to remove the names of patients who aren't parties in the lawsuit. Documents that require redacting usually don't include medical records because those are specific to the patient whose case is in litigation.  Instead, documents that need to be redacted are those that could violate the confidentiality of other patients.  These types of documents include:

1)   Sign-in sheets at doctor's offices. These are often used to infer that a physician saw so many patients on a particular day that the physician didn't spend enough time with the plaintiff to correctly make a diagnosis.

2)   Schedules which include the names of other patients. For example, a schedule sheet for Radiology could be used to pinpoint the time a patient was in that department. An operating room schedule could be used to determine if a surgeon operated for an unusual length of time on a particular day or operated in an assembly line fashion on many patients that day resulting in carelessness by the surgeon.

3)   OB Delivery logs.  Delivery logs can be compared to staffing assignment sheets to determine if staffing was adequate.  For example, if several deliveries occurred at the same time, a plaintiff with a bad outcome may infer that the bad outcome was caused by inadequate monitoring by the delivery room nurses.

Staff assignment sheets.  Staff assignment sheets can identify which staff members cared for the plaintiff. If the assignment sheets show that the staff member caring for the plaintiff was assigned to a large number of patients, the plaintiff may infer that inadequate attention was paid to the plaintiff resulting in a poor outcome.

4)    Visitor logs that require the visitor to write which patient is being seen. These are often used in nursing home cases by the defense to show that family members rarely visited their relative. The defense may infer that family members started the lawsuit for to gain money and not from concern about the patient.

Redacting documents is straightforward but still can be done incorrectly as shown in the image below (the patient name is not real).  As you can see, when the image is enlarged or viewed with a magnifying glass, the patient's name can be seen.

What's the correct procedure to redact a document?

1)   Make a copy of the document you're going to redact. The copy will be your working copy. Never redact an original document.

2)   Use a scissors, white correction fluid, white correction tape or a a black permanent marker to completely cross out the patient's name and any other identifying information such as a social security number or medical record number. If you use scissors, you will cut out names and other identifiers and you will need to shred the information you remove. In the example below, a black permanent marker was used.

3)   At this point, the name may still show through if it's held to the light. To make sure that the name is not visible, make a copy of your working copy. This copy of your working copy will be the document that is provided to opposing counsel.

Your properly redacted document will look something like this:

If you want your document to look tidier than the example above, you can scan the document and electronically redact it using Adobe Acrobat Professional or other redaction software.

As a new LNC, you can now redact documents. And you can redact them correctly and professionally.

Want to learn more about LNC skills for legal nurse consultants? Check out the Archives.

...Katy Jones