Tampering In the Medical Record

- Laurie Miles R.N.C., M.B.A., C.L.N.C. -

Documentation is one of the most critical skills that healthcare providers perform.

It is, at its best, a systematic detailed view of the patient’s condition, the healthcare provider’s actions and the patient’s responses to those actions. It is critical for patient care and safety, as it is a communication tool between the healthcare providers, and it is the evidence of the patient’s care. Undocumented care or failure to document is a deviation from the standard of care. It is a known and accepted nursing standard that all care provided will be documented, and lack of documentation is evidence that the care was not provided.

Healthcare providers have an obligation to maintain professional practice standards of documentation for their profession. Clarity, conciseness and consistency is the goal. Maintaining an accurate and complete medical record of the patient’s care that meets professional standards is an obligation. In the field of nursing, standards of care and standards of documentation are not set by any one body. Rather they are developed over the years by the nursing profession itself and set forth by professional organizations such as the American Nurses Society (ANA), and the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

There are individual state laws that speak to nursing practice, but usually specific criteria that addresses documentation is not given. Most nurse practice acts do site documentation as part of the nurse’s responsibility. All licensed nurses, in whatever practice setting they work, are required by their state licensing board to know and follow their state’s Nurse Practice Act. To deviate from the Nurse Practice Act is to risk having disciplinary action against one’s license up to and including revocation of the license. In addition, all states have a mandatory amount of continuing education per year for a provider. It is a duty to maintain knowledge and competency of one's own practice.

The obligation to meet the standards of documentation do not differ from state to state or nurse to nurse, thus a nurse in California and a nurse in New Jersey must both be meeting the current and accepted practice standard of good documentation. All licensed nurses must have graduated from an accredited school of nursing prior to taking standardized national licensure exams. School curriculum of an accredited school includes teaching of documentation as well as actual clinical practice of patient care and it’s documentation.

Having said that, anyone having read a medical record has seen that there are varying degree’s of professional documentation in any medical record. Issues of legibility, little to no information, poor detail, no patient response, no consistency are just some of the problems to be found in a medical record.

One might ask, exactly what are these standards? Appropriate documentation format includes one line of writing per line on a page, all entry's dated, timed in a chronological order, signed and the use of only standardized medical abbreviations. Late entries labeled as such with a time and a date of the writing as well as the date and shift the entry pertains to and explanation of why the entry is late is considered the appropriate format. Individual facilities have policies and procedures related to specific forms being used or frequencies of documentation that must be followed. These are all standards of care.

When numerous late entries are seen in a medical record, it is a suspicious situation. Any time different inks are seen within one entry, it is suspicious and tampering should be considered. Different handwriting within one entry is also an indication that there is a problem.

When the following questions arise: Has there been altering of the information in the medical record? Did anyone add additional information to the medical record after an incident to mislead or cloud an issue? Are there parts of the medical record that are missing? It is at this point that it is vital that an expert in the professional field reviews the medical records.

An expert in their own field knows exactly what to look for that would indicate problems in the medical record. Such an expert knows to compare, how to cross check one area of information with another to check the validity of both and also what medical records are missing.

Examples of altered medical records and suspicious charting:

• A tube feeding is charted as being administered daily with the same initials for a period of 16 days. This raises suspicion to the care provided as medical staff do not generally work extended periods of time without a day off. Further suspicion as to the accuracy of the medical record arose when it was found that the patient was not in the facility, but rather hospitalized elsewhere when this tube feeding was charted as being administered.
  
  
• A nurse initials on her nursing flow sheet that she repositioned a patient on his right side at 0900 and left side at 1100 while a respiratory therapist flow sheet note at 0900 and 1100 states the patient was found lying on his back each time. The documentation of positioning a patient would be of vital importance when a claim of pressure ulcers or bedsores was alleged as lack of positioning is associated with the development of these wounds. These notes are in different sections of the chart, perhaps separated by numerous inches of medical records. A registered nurse familiar with standards of practice would look for and compare information from multiple sources within the medical records and be familiar with the usual and accepted practices of a health care facility.
  
  
• A patient’s plan of care calls for feeding the patient all meals. The nursing assistant’s flow sheet has numerous blank spaces instead of initials where documentation of meals should occur. The patient is losing weight. If it is not documented, it was not done.
  
  
• There are late entries present that entirely change what was written at the time of the incident, or there are late entries that do not follow the accepted format for entering a late entry.
  
  
• There might be missing documents that pertain to the time of the incident.
  
  
• There might be a failure to document on a consistent and timely basis.
  
  
• There may be squeezed-in entries, that may indicate documentation at a later time.
  
  
• There might be duplicate documents that state entirely different things written several days apart.

To be sure that the medical records are accurate, complete and do not contain evidence of tampering, it takes an expert in the field, knowledgeable of what is current accepted practice, to look for and locate any of these issues that could be present in the medical record or confirm their absence.

The altering of medical records and tampering in the medical record does take place. Poor documentation, no documentation, poor care, great care, the medical record is the evidence of it all and of all the care provided or not provided to the patient.

If you have a question of altering or tampering in the medical record, ask a professional experienced in documentation in the field to review those medical records. You may be surprised by what we can find.

Biography

Ms. Miles is certified as a Legal Nurse Consultant. She has practiced as a Registered Nurse for thirteen years with prior practice as Licensed Practical Nurse. She has an Associate Degree in Nursing, Bachelor's Degree in Behavioral Sciences-Psychology and Master's Degree in Healthcare Administration, graduating Cum Laude.

Ms. Miles is experienced in and knowledgeable of federally recognized quality care criteria and standards, i.e. Interqual software, Medicaid, Medicare and JCAHO regulations and standards. She has provided thousands of quality assurance reviews through a peer review organization, insurance companies, attorneys and health care facilities.

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