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Error or fraud? The importance of accurate patient charts

On Behalf of | May 25, 2017 | blog

The nursing profession brings opportunities for joy and heartache. Daily, you meet people who are in need, and you provide comfort and reassurance in addition to medical assistance. Even though many days you go home feeling exhausted and defeated, you may still agree that choosing a career as a nurse was a good decision.

However, the pace of the medical facility where you work may be demanding, and sometimes you may not be able to complete your documentation in a timely manner. While this may never have caused you trouble in the past, now you are facing accusations of fraud for intentionally falsifying patient records. You may have concerns about your future.

False documentation

Accurate logs of patient care are essential for medical professionals to be able to provide adequate treatment. Additionally, such information protects you and your medical team by providing evidence of procedures in case patients question the standard of care they receive. Misrepresenting the truth in a patient chart is fraud if you do it intentionally. Some mistakes that commonly result in faulty record keeping include the following:

  • Trying to fill in charts at the end of a busy shift instead of immediately after completing each task
  • Missing a dose of medication or some other task but recording that you completed the task to avoid discipline
  • Writing illegibly, which a judge or jury can interpret as a sign of careless nursing
  • Omitting documentation of patient refusals, changes in patient status, efforts in an ongoing process or evidence that the patient understood discharge instructions
  • Omitting that you objected to a treatment plan or that you delegated a task to another staff member
  • Documenting when an adverse event occurs

In some cases, you may make a simple mistake like leaving a space blank or filling in a space that another nurse skipped. These actions may create confusion in the record keeping and may provide ammunition for a patient who subsequently files a lawsuit.

An advocate for your nursing license

Facing a hearing in front of the State Board of Nursing can be daunting. With your license on the line, you may also fear for your financial security and the well-being of your family. If the Board has alleged that you falsified patient charts, you also face a felony charge for which you may be considering legal representation. However, a criminal defense lawyer does not necessarily have experience in professional licensing issues.

Having an attorney whose primary focus is the defense of medical licenses will offer you a significant advantage. Your attorney will be familiar with the process and the expectations of the Board and will protect your rights every step of the way. You will benefit from having such an attorney on your side as soon as you are aware of the allegations against you.