Adopt better record keeping practices, privacy commissioner tells doctor who altered records of dead patient

The Saskatchewan Information and Privacy Commissioner, Ron Kruzeniski, is recommending that a doctor who altered an electronic record of a dead patient's visit eight times after the patient's death do a better job at keeping medical records.

Dr. Svitlana Cheshenchuk altered a record of a visit from Sandra Hendricks, who died hours after leaving a check up with the doctor back in 2014. The alterations took place between October 2014 and June 2015.

The privacy commissioner found that the doctor did not comply with multiple sections of the Health Information Protection Act (HIPA), which are related to policies which should protect the integrity and information and its compliance with HIPA.

"Integrity refers to the condition of information being whole or complete; not modified, deleted or corrupted," the report reads. 

Kruzeniski recommends that: 

• Cheshenchuk research best practices regarding blocking access of personal health information of individuals and create a Privacy Impact Assessment (PIA).
• That Cheshenchuk submit the PIA to the office of the privacy commissioner for review.
• That Cheshenchuk research best practices with respect to the timeliness of completing notes, making corrections to personal health information and adding late entries to personal health information.
• That Cheshenchuk develop policies and procedures on these topics that reflect best practices. She should also ensure that her staff is educated with respect to the new policies and procedures.

Cheshenchuk later admitted guilt to professional misconduct with the College of Physicians and Surgeons of Saskatchewan for the alterations. The doctor was given a month-long suspension and fined more than $7,000.

Specifically, she admitted guilt to failing to maintain Hendricks' record, making several alterations to the record, not completing the record in a timely manner, and failing to exercise due diligence to ensure that the information in the record accurately reflected the care provided to Hendricks. 

Cheshenchuk is now the subject of a lawsuit filed by Hendricks' daughter, alleging the doctor was negligent in her treatment of Hendricks and that she failed to send her to the hospital.

Hendricks wasn't feeling well on Oct. 17, 2014 and went to see Cheshenchuk at the Quance East Medical Clinic in Regina.

Cheshenchuk conducted an electrocardiogram because she suspected a heart attack and sent the data, marked urgent, to another doctor to read it.

Hendricks left the office — equipped with a prescription for antibiotics and an inhaler — before the results were sent back. The prescription was filled at 2:14 p.m.

The second doctor sent a response back to Cheshenchuk at 2:20 p.m. indicating that the ECG was abnormal, according the statement of claim.

Hendricks died of heart failure around 5:00 p.m.