Falsification of Medical Records – Creates Grave Consequences for the Patient and Provider

Healthcare providers turning rogue is a really frightening prospect. These are people who you trust with your lives, and they are bound to offer you the best care and services. Unfortunately it is not always so. There have been many cases where physicians and nurses have falsified medical records in an attempt to cover something up or with a view to fraudulent insurance billing. Now, this is something very serious because medical records that are used for reviewing the patient’s health condition and administering the right treatment and for medical record review purposes must be accurate with no margin for error. However, if care providers turn callous and negligent, there is no limit to the injuries patients may suffer.

Falsifying Medical Records at the Expense of Patient Care

In a recent such case involving falsified medical records, a registered nurse at St. Peter’s Hospital in Albany was arrested and arraigned. She made false entries into the medical records of two patients at the hospital in order to steal medications that included narcotics. The incident occurred in 2014 – the nurse falsely documented the administration of the controlled substancesOxycodone-Acetaminophen (Percocet) and Diazepam (Valium) when in fact she never administered these medications.

The Attorney General who announced the arrest and indictment of the nurse made it clear that medical professionals who abuse their authority to dispense medications at the expense of patient care will be held accountable. Healthcare providers cannot put their own interests above those who entrust them with their care. The 38-year-old nurse who was released on her own recognizance in this case was indicted on charges of Falsifying Business Records in the First Degree, a class E Felony, Criminal possession of a Controlled Substance in the Seventh Degree, a class A Misdemeanor, and Petit Larceny, a class A Misdemeanor.

In another case a registered nurse in Rochester, NY pleaded guilty in a criminal court case involving neglect of an elderly resident. This nurse was also charged with Falsifying Business Records in the Second Degree, a class A misdemeanor–- she failed to administer the blood thinning medication Lovenox to a resident on many occasions. She covered up the failure by charting the administration of the medication in the resident’s medical records.

Charting is a very important process in a nursing home environment, as any expert reviewer providing medical record review for attorneys would point out since the integrity of the chart is the most important thing that enables flawless transition between various nursing shifts, ensuring continuity of care. The misdemeanor of the nurse proved costly to the resident who developed deep vein thrombosis (DVT) in the legs. It is actually a dangerous condition since the clot formed can travel to the lungs and lead to death. Fortunately, in this resident’s case, the DVT was treatable and there were no dangerous complications.

The above mentioned cases are clear and alarming indications of the fact that in a healthcare setting, you may not always be safe. It is important for providers to assure that their patients are safe and secure. They should also understand that medication errors resulting in injury to patients is a deprivation of the patients’ legally afforded rights, and providers will be held accountable for the patients.

A Punishable Offense

In New York, the crime of falsifying business records is categorized into two degrees.Class A misdemeanors (the lesser offense of the second degree) can be punished by conditional discharge or up to a 1 year conditional sentence, after the conviction. The punishment is significantly more severe for the first degree version of the crime, a Class E Felony. In this case, the person could face a minimum of 1 to 3 years in prison and a maximum of 1 1/3 to 4 years.

The Medical Record – an Important Legal Document

The medical record is the primary focus of scrutiny in personal injury, medical malpractice and medical device liability lawsuits. Inappropriate alteration as well as falsification of medical records can have an adverse impact on the credibility of the medical record and the integrity of the practitioners who created the records. Medical record entries that appear self-serving can do a great deal of damage, and such entries are easily identified during a comprehensive, expert medical record review.

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