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A healthcare practitioner who is found to have falsified medical records almost certainly will be subject to discipline by the state licensing board – right up to license suspension. Even if she's not suspended, the practitioner's insurer likely will cancel professional liability cover.
In some states, tampering with medical records is a criminal offense in its own right. In others, fabricating medical entries is a forgery crime, covered by both state and federal laws.
Lastly, the practitioner can surmise that this episode is severe in that it caused the patient to require admission to the inpatient psychiatric unit and the patient is exhibiting poor insight and judgment indicating a poor level of functioning.
This is assessed by asking the patient if they know their name, current location (including city and state), and date. Someone who is normally oriented fully but is acutely not oriented may be experiencing substance intoxication, a primary psychiatric illness, or delirium.
While the phrase "falsifying medical records" sounds rather sinister, in fact it covers a number of activities that may not always have a fraudulent intent. For example, a physician may face allegations of wrongdoing if she tampers with the records to make it look like she did something she did not, ...
When medical records are fraudulently falsified, it's usually in response to a medical malpractice suit. For example, a physician who is being sued for damages might alter the records to cover up his wrongdoing and make the records fit his version of the story. These actions will destroy a medical malpractice defense.
A healthcare practitioner who is found to have falsified medical records almost certainly will be subject to discipline by the state licensing board , which could range anywhere from a reprimand to a fine to license suspension or even loss of a license.
Even if she's not suspended, the practitioner's insurer likely will cancel professional liability coverage. This means the practitioner's legal bills won't be covered if she's sued for medical malpractice, which may harm her ability to defend the case.
In some states, tampering with medical records is a criminal offense in its own right. In others, fabricating medical entries is a forgery crime, covered by both state and federal laws. Misdemeanor tampering charges typically will result in fines and jail time up to around a year.
Even non-medical professionals can get in trouble for falsifying medical records. You can't go into the hospital and make changes to your sister's chart, for example, because you want her to get more medication, because you want her released or even because you want to create a beneficial situation for a medical malpractice lawsuit or personal injury lawsuit. Falsifying medical records, whether you're a medical worker or not, is illegal.
A delayed speech response time may also indicate a neurocognitive disorder or that the patient is experiencing a thought process disorder such as thought blocking seen in psychosis. The rhythm of speech can provide clues to a number of diagnoses. Slurred speech may indicate intoxication.
Abstract reasoning is a patient’s ability to infer meaning and concepts.
In a loose, disorganized thought process, there is no connection between the thoughts and no train of thought to follow. [5] Perseverations are a type of thought process where no matter the topic or question, the patient goes back to the same subject.
A comatose patient is unresponsive to all stimuli, including vigorous and noxious stimuli. [6] An altered level of consciousness or sensorium may indicate that a patient may have had a head injury, ingested a substance, or have delirium from another medical condition. [9]
The qualities to be noted are the amount of verbalization, fluency, rate, rhythm, volume, and tone. It is of key importance to note the amount a patient speaks. If the patient speaks less than normal, they may be experiencing depression or anxiety.
Motor activity can indicate an underlying mental illness or neurological disorder. Furthermore, as the dopamine system targeted by medications plays a vital role in the movement, it is especially essential in monitoring for medication side effects. One aspect of monitoring is the speed of movements.
For the purposes of this activity, the mental status examination can divide into the broad categories of appearance, behavior, motor activity, speech, mood, affect, thought process, thought content, perceptual disturbances, cognition, insight, and judgment.
Once inflated, the cuff compresses the brachial artery, momentarily stopping blood flow. Next, air in the cuff is slowly released while the person performing the measurement listens with a stethoscope or monitors an electronic readout.
Once inflated, the cuff compresses the brachial artery, momentarily stopping blood flow.
The best way to diagnose high blood pressure (HBP or hypertension) is to have your blood pressure measured. A blood pressure reading is taken with a pressure cuff (sphygmomanometer). During the test, the cuff is placed around the upper arm before being manually or electronically inflated.
Diastolic blood pressure (the bottom number) — indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats. Learn more about what your blood pressure numbers mean.