36 hours ago · Falsification in any record in connection with your nursing practice is unethical and violates many laws. N.B. is now a convicted felon who will most likely be unable to work in the health care field again due to the nature and the numerous incidents of her falsified entries. The state nurse practice act is another area of liability. >> Go To The Portal
Patient records are legal documents, and the courts do not respond favorably when they have been falsified or tampered with. "Doctored" data can throw into doubt the basis of a diagnosis, the treatment plan and communications with the patient, which in turn can have serious implications for the quality of patient care.
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Unfortunately, falsification of documents in nursing is not a new phenomenon. A 2012 article in the Journal of Nursing Regulation by Latrina Gibbs McClenton, discusses two cases of falsification of licensure applications by two separate candidates applying for RN licensure in Mississippi.
Patient records are legal documents, and the courts do not respond favorably when they have been falsified or tampered with. "Doctored" data can throw into doubt the basis of a diagnosis, the treatment plan and communications with the patient, which in turn can have serious implications for the quality of patient care.
Falsification by nurses is not only unethical, it shatters legal parameters. Initially, criminal charges on the state or federal level may be brought against the nurse.
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.
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.
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.
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.
Specifically, the owner removed all references to the patients’ ambulatory status, in order to help establish the need for ambulance. This case also involved significant penalties and a jail sentence for the owner.
Patient representatives (guardians, POA, family members, even facility representatives who previously cared for the transport) A combination of crew and receiving facility representatives acknowledging the patient was unable to sign and that none of the other representatives were willing or available to sign.
For example, in Pennsylvania, “a person is guilty of forgery if ( intending to defraud or under knowledge of facilitating fraud), he or she alters a writing without authority, or executes a document so that it purports to be the act of another who did not authorize the act.”.
A crewmember signing a patient’s name without the patient’s consent meets the legal definition of forgery. The potential penalty for fraud lies with the perpetrator. It is not just a mistake that might result in potential Medicare overpayment (ultimately refunded by the company). It is a criminal act for which the forger can be personally liable.
However, it might be very hard for a biller (or anyone for that matter) to detect a forged signature. Consider the numerous signatures required for ambulance transports:
No matter the reason, the practice is illegal and should never be done. As care providers, we owe a duty to the patients. This duty extends far beyond simply providing pre-hospital care. It includes providing proper documentation of the care provided and meeting all compliance expectations including getting the patient signature (where the patient is physically and mentally capable of doing), or other valid signatures for claim submission purposes and not forging the patient’s signature.
Regardless of how or what crewmembers document (or are told to document) on a patient care report, billers and coders must still make an informed decision as to how to bill the claim. Thus, fraud potentially comes with billing decisions, and/or instructions from superiors, and not directly by actions (or inactions) of crewmembers.
Other examples of nurse falsification with patient care matters include inaccurate entries; medications and treatments documented as being given when they are not; covering up bad outcomes; and staff simply documenting in charts “en masse,” not knowing for sure whether what is being recorded is accurate (“Falsified Patient Records Are Untold Story of California Nursing Home Care,” California Advocates For Nursing Home Reform).
The Texas Board of Nursing, in its publication “Behavior Involving Lying and Falsification ,” gives examples such when an individual pretends to be a nurse or when a nurse licensee may represent that he or she has a “broader scope of practice” than is actually authorized by his or her license.
In most states, disciplinary actions include a reprimand, censure, probation, suspension or revocation of the nurse’s license. “When anyone falsifies information about themselves, it is a serious matter, as it is obviously misleading, deceptive and reflects on your trustworthiness. But it is extremely serious when a nurse does this.”.
Unfortunately, falsification of documents in nursing is not a new phenomenon. A 2012 article in the Journal of Nursing Regulation by Latrina Gibbs McClenton, discusses two cases of falsification of licensure applications by two separate candidates applying for RN licensure in Mississippi. McClenton identifies falsification in such instances as a result of “deception or omission” and includes failure to disclose a criminal history, listing or claiming an educational degree that the applicant does not possess, and using personal information taken from another to apply for licensure.
State boards of nursing can initiate professional disciplinary proceedings against a nurse when falsification occurs, including in cases when unprofessional conduct is likely to deceive, defraud or harm the public; using false, deceptive or fraudulent statements in any record in connection with a nurse’s practice; practicing beyond the scope of one’s practice; and violating state or federal laws, rules and regulations governing controlled substances. In most states, disciplinary actions include a reprimand, censure, probation, suspension or revocation of the nurse’s license.
“Falsification by nurses is not only unethical, it shatters legal parameters. Initially, criminal charges on the state or federal level may be brought against the nurse.”. Other examples of nurse falsification ...
The nurse certainly could try to report her concerns to the CNO, who should appropriately intervene in the situation. Or the nurse could report the situation to her state board of nursing, which would investigate the matter and determine if disciplinary proceedings should be initiated. The bottom line is that the reader is describing an example of falsification, which is the willful perversion of facts and includes such behavior as lying, distorting and paltering.
Medical records form an important part of the management of a patient. It is important for the doctors and medical establishments to properly maintain the records of patients for two important reasons. The first one is that it will help them in the scientific evaluation of their patient profile, helping in analyzing the treatment results, ...
The doctor is the prime person who has to oversee this process and is primarily responsible for history, physical examination, treatment plans, operative records, consent forms, medications used, referral papers, discharge records, and medical certificates.
Referral notes. Referral notes are an important component of patient records. They should include the date and time of issue, the patient's general condition, cause of reference, and the course of action to be taken.
An undated prescription can land a doctor in trouble if the patient misuses it. There are also many records that are indirectly related to patient management such as accounts records, service records of the staff, and administrative records, which are also useful as evidences for litigation purposes.
It is important to give due importance to making a proper discharge summary as this is the summary document that will be kept by the patient which reflects the treatment received.
This requires a formal application to the hospital requesting for the records. It is necessary that the hospital bills are cleared and the necessary processing fee has been paid. The documents in this group include copies of inpatient files, records of diagnostic tests, operation notes, videos, medical certificates, and duplicate copies for lost documents. It is important that the duplicate copies should be marked appropriately. It is not unusual for an unscrupulous patient to use it for multiple insurance claims without the knowledge of the doctor.
Medical record keeping has evolved into a science of itself. This will be the only way for the doctor to prove that the treatment was carried out properly. Moreover, it will also be of immense help in the scientific evaluation and review of patient management issues.
Emergency Care in the Streets Chapter 6: Documenta…
C) is a nationwide billing system that any EMS provider can use.
If the paramedic is unable to complete his or her patient care report before departing the emergency department, he or she should: A) leave, at a minimum, the patient's name and age, but recognize that the physician will perform his or her own exam.
D) insurance companies do not pay if unapproved abbreviations are used .
Altering a medical record implies tampering with the evidence. Such proof will destroy the defendant’s credibility before a jury and will leave the strong impression that he or she is trying to hide the truth. Evidence indicating that a record has been altered can force the settlement of an otherwise defensible case.
Medical records which are undated, illegible, incomplete or clearly erroneous can be used by a plaintiff to cast doubt upon the quality of care the patient received from the provider. Proof of medical record alteration, without good cause and proper authentication, has serious consequences in malpractice litigation. Altering a medical record implies tampering with the evidence. Such proof will destroy the defendant’s credibility before a jury and will leave the strong impression that he or she is trying to hide the truth. Evidence indicating that a record has been altered can force the settlement of an otherwise defensible case.
In addition, if a provider is sued for medical malpractice, an improper alteration of the patient’s medical record may very well destroy his or her ability to defend the case. This is true even if the medical care in question was entirely appropriate. The medical record is one of the most essential tools in the defense arsenal.
However, alteration of a medical record can carry serious consequences for the practitioner. For example, proof that a medical record has been intentionally altered can result in the cancellation or non-renewal of an insured’s professional liability insurance policy. In addition, if a provider is sued for medical malpractice, ...
Accurate and complete medical records are essential for quality of care, compliance with payment requirements and for use in legal proceedings. There is a tremendous amount of pressure on providers to timely document all facts surrounding their patient interactions. Unfortunately, at times, the medical record is unclear, incomplete or inaccurate.
The medical record is one of the most essential tools in the defense arsenal. It documents the patient’s history, the provider’s thought process, the basis for the diagnosis and treatment, and communications with the patient.
Unfortunately, at times, the medical record is unclear, incomplete or inaccurate. A provider may not realize the inadequacies in his/her documentation until faced with a patient complaint, a professional misconduct investigation or lawsuit.
share information with the EMS providers about patient outcome for purposes of quality assurance and education.
patient information shall not be shared with entities or persons not involved in the care of the patient.