Patient records are legal documents, and the courts do not respond favorably to accusations that 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. Altering a medical record can lead to a world of trouble for the medical practitioner, even if the alteration just clarifies what actually occurred.
Medical practitioners who falsify medical records face criminal penalties, punitive damages and discipline by the state licensing board.
Meaning of Falsifying Medical Records
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, but she may face the same allegations simply by adding a detail she left out. To safeguard the chronology of events, any corrections should have their own date and time, with additional notes to explain why the entry was added later.
Felony Forgery Charges
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. A felony forgery conviction, on the other hand, may result in heavy fines up to $250,000 and possible imprisonment in a federal facility for up to five years. To prove forgery, there must be some element of fraudulent intent, for example, where a physician alters records to improve his defense in a medical malpractice suit.
Kiss of Death for a Medical Malpractice Defense
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 are the kiss of death for a medical malpractice defense. If forensic experts uncover evidence of tampering, it shows the physician knew he did something wrong and tried to hide it. This sabotages the physician's defense and he likely will lose all credibility with the court.
Insurance and Regulatory Issues
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. 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.