23 hours ago · Reviewed by: Rebecca K. McDowell, J.D. December 09, 2018. By: Jayne Thompson, LL.B., LL.M. •••. 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 … >> 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.
Full Answer
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.
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.
The accuracy of your patient care report depends on all of the following factors, EXCEPT: A) including all pertinent event times. B) the severity of the patient's condition. C) the thoroughness of the narrative section. D) documenting any extenuating circumstances.
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.
Healthcare providers may also lose accreditation, eligibility for federal reimbursement programs, and loss of trust if they are found to have falsified a patient's medical record. Finally, knowingly falsifying medical records is a felony crime with a potential fine of $250,000 or five years in prison.
If your facility participates in Medicare or Medicaid, charting falsifications can be prosecuted as federal criminal offenses. The nurse who falsifies the record could lose her license and possibly serve prison time.
The consequences of incomplete medical records are: Lack of clarity in communication between physicians treating the patient leading to failure to follow through with evaluation and treatment plans. Incorrect treatment decisions compromising patient safety. Loss of practice revenue.
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.
BACKGROUND: Inaccurate and incomplete documentation can lead to poor treatment and medico-legal consequences. Studies indicate that teaching programs in this field can improve the documentation of medical records.
Falsification raises concerns about the individual's propensity to lie and the likelihood that such conduct may continue in the practice of nursing. Depending on the particular circumstances, disciplinary action may be warranted.
Inaccuracies in data lead to poor decision-making. This is because healthcare providers are becoming increasingly reliant on electronic medical records, which means any data inconsistencies or inaccuracies could prevent the organization from making informed decisions.
A violation of HIPAA committed under false pretenses, such as disclosing a patient's information for a reason the provider knows to be untrue (such disclosing a patient's protected health information on the premise that the patient is an imminent threat to the public when the provider knows this to be false), can carry ...
Patient safety is compromised One of the biggest issues of unclean data is that it impacts patient safety. One patient will receive inaccurate and even dangerous treatment because they are being treated based on an entirely different patient's medical record.
As much as nurses try to avoid it, ethical violations do occur. Breaches in nursing ethics, depending on the incident, can have significant ramifications for nurses. They may face discipline from their state board of nursing, or from their employer. They can also face litigation.
The most frequent reason for discipline is practicing while impaired. SBNs set and enforce minimum criteria for nursing education programs. Schools of nursing must have state approval to operate.
False documentation is the process of creating documents which record fictitious events. The documents can then be used to "prove" that the fictional events happened.
It was prejudiced in that her conduct could result in civil penalties, loss of licensure, or closure of the facility.3
Repercussions of her inaccurate documentation clearly “prejudiced” J.E. because he did not receive important medications and treatments as ordered.
on the four counts of forgery because the evidence at the trial level proved her guilt beyond a reasonable doubt. Moreover, the Court opined, the disqualification of N.B.’s attorney was correct and therefore no new trial was required.
The trial record below, however, indicated that N.B. made at least 50 documented false entries and therefore there was evidence of fraudulent intent. N.B.’s conduct was not an isolated event, the Appellate Court held, but was a “pattern of behavior to misrepresent the patient’s treatment and medications.”
argued that even if she failed to accurately document what care she did or did not provide, that alone does not prove intent to defraud. She also argued that there was no proof that she “benefited” from her conduct.
N.B’s argument that she derived no benefit from her conduct was also struck down by the Court. To begin with, she was paid for the time she worked at the nursing home and also benefited from “masking her dereliction” of her duties to the patient.
The video surveillance is this case, along with the forged documentation, helped provide evidence beyond a reasonable doubt of N.B.’s guilt. Although you may never experience being filmed while you provide care, other means exist to prove whether nursing care was provided.
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).
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.”.
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.
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.
If you believe that a health care provider has engaged in any of the conduct or practices described above, you should promptly contact the insurance carrier that sent the payment notice to you. Alternatively, you may contact one of the agencies or offices listed below to report the discrepancy, irregularity, or other problem that you have identified:
In 2003, federal prosecutors throughout the country obtained some 500 criminal convictions of individuals and corporations for health care fraud-related actions, and approximately 3200 health care providers were excluded from future participation in Medicare and related federal programs. In 2004, the USAO continues to pursue actively ...
The Office of the United States Attorney for the Western District of Michigan (USAO), the local branch of the United States Department of Justice, is dedicated to prosecuting individuals, groups of individuals, institutions, and businesses that engage in health care fraud. In that effort, the Criminal and the Civil Divisions of the USAO work closely and effectively with various law enforcement agencies to identify and investigate all varieties of this misconduct; those agencies include the Office of the Inspector General of the United States Department of Health and Human Services, the Federal Bureau of Investigation, the Defense Criminal Investigative Service, the Drug Enforcement Administration, the Internal Revenue Service, the United States Postal Inspection Service, and the Office of the Attorney General for the State of Michigan. The USAO also works collaboratively with investigators and auditors of private insurance companies.
For approximately five years, fiscal intermediaries and carriers for Medicare have been required, in virtually all circumstances, to send notices and explanations of benefits to Medicare users and patients . It is critically important that all beneficiaries review and verify the information on these documents–and that they question any entries or notations that are inconsistent with or unrelated to the actual health care services provided. In particular, you should be especially attentive to and questioning of notices and explanations that memorialize:
Nationally, the United States Department of Justice, in collaboration with other federal and state agencies, recovered approximately $1.8 billion in criminal and civil health care fraud prosecutions in 2002 alone and returned approximately $1.4 billion of that to the Medicare Trust Fund. In 2003, federal prosecutors throughout ...
The civil disposition of false claims charges may also include injunctive and declaratory remedies –that is, preventing the defendants from engaging further in publicly-identified conduct–in addition to temporary suspensions or permanent debarments from participation in Medicare and related programs.
Fraud in our nation’s health care system, including that in the Western District of Michigan, results in losses of millions of dollars every year from the Medicare, Medicaid, and private insurance programs . Beneficiaries and other recipients of health care pay for these significant losses through higher premiums, increased taxes, and reduced services.
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.
A significant portion of revenue is related to volume, which includes new and repeat patient visits. Although there are some publicly available quality metrics, like the results of the HCAHPS surveys [3], patients often make medical decisions based on reputation and word of mouth. Thus, physicians need to focus on patients’ satisfaction with care because it may drive patient volume more than technical acumen alone. Another reason physicians might focus on patients’ experience of care is that there is evidence suggesting that “the frequency with which physicians are sued is related in part to patients’ satisfaction with interpersonal aspects of medical care” [10, 11]. While these may not be the primary reasons for physicians to focus on patients’ experience of care, doing so may actually provide operational benefit, in addition to better patient care.
Another reason physicians might focus on patients’ experience of care is that there is evidence suggesting that “the frequency with which physicians are sued is related in part to patients’ satisfaction with interpersonal aspects of medical care ” [10, 11].
HCAHPS is the most studied system for measuring patients’ experience of their care on an individual and hospital level [7] , so it is a useful step towards helping clinicians think more broadly about outcomes that matter to both them and their patients.
Patient experience scores may also have an association with more objective clinical quality measure scores. For example, hospitals with better patient experience scores also have some higher quality measures for acute myocardial infarction and aspects of surgical care [7-9]. There are two possible explanations for this relationship. First, hospitals that have better engagement with patients may encourage greater adherence to clinical standards of care and follow-up. Patients who are more satisfied with a practice may be more likely to come in for visits and follow the recommendations of the clinicians that they trust. Second, better patient experience scores could indicate that a hospital has stronger teamwork, organizational leadership, and commitment to improvement, characteristics that could be associated with better quality measures and patient experience scores. Both of these possible explanations suggest that there is benefit for clinicians in measuring and rewarding patient experience of care, since doing so has the potential to improve overall quality of care.
As part of its “triple aim,” the Institute for Health Care Improvement describes the patient experience of care as including both care quality and patient satisfaction, suggesting that these features are interrelated [6]. Regardless of whether one considers experience an indicator of quality, improving patient experience ratings is beneficia l for patients and clinicians for a number of reasons.
Physicians can no longer choose not to participate in, but they can decide how best to engage with, incentive programs. Hospitals and clinics are using these scores to justify greater investment in improving experience for patients—a big step for an industry not known for customer service.
But all of these are objective measures. Patient satisfaction just isn’t an objective measure of care quality.”.
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.
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 .