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Falsification of Medical Records

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Falsification of Medical Records

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Falsification of Medical Records

LPN faces criminal charges after covering up a medication transcription error

Nurses have long been advised that a patient's medical record is a legal document that may not be altered or falsified. Errors are to be indicated as such by placing a line through the entry, along with the initials of the author, date and time. Nurses also have been taught that the rationale for accurate and truthful charting is to "preserve" the chart as a record of the care and treatment rendered to the patient in the event that a medical malpractice suit is brought. Since the nurse will likely not be able to recall the past events leading to the malpractice suit, the medical record serves as the means to both refresh recollection and substantiate the treatment and care rendered.

In addition to the threat of a malpractice suit, nurses are aware that discovered and verified medical record falsification could perhaps lead to licensure sanction by the state board of nursing and disciplinary action by the nurse's employer.

It is a fair and accurate statement that few, if any, nurses would anticipate or otherwise expect prosecution by the federal government, with the prospect of a prison term for such an act. However, in a recent action brought by a federal prosecutor in Philadelphia against an LPN, that is exactly what happened.

Relevant Alleged Facts
In this first case of its kind in the nation, an LPN working in a Pennsylvania nursing home has been criminally charged with attempting to cover up a medication transcription error regarding a resident who later died.

The resident was admitted to the nursing home 4 weeks before her death. Allegedly during the resident's stay, the LPN received a verbal order to reduce the resident's anticoagulant medication. A short time thereafter, the resident's condition worsened, and the LPN realized that she failed to transcribe accurately the order to reduce the anticoagulant medication. The LPN then allegedly falsified the resident's medical record to indicate that the physician order had been implemented correctly. It was this alleged falsification of the medical record, not the initial error itself, which formed the basis for the criminal charges.

The False Claims Act
The law used by the federal prosecutor to prosecute the LPN has never been utilized in this way before. This federal law was incorporated into the 1996 Health Insurance Portability and Accountability Act (HIPAA), and precludes the making of "false statements" in a matter involving a federal health care benefit program. The health care benefit programs that are usually involved are the federal Medicare and Medicaid programs.

The penalties involved for such false statements are a maximum term of 5 years imprisonment and/or a $25,000 fine. Additionally, the conviction may serve as the basis for mandatory exclusion from participation in the Medicaid and Medicare programs. If excluded, the individual could never again work for an entity that bills either Medicare or Medicaid for health care services the entity provides.

The law was intended to deter and punish the knowing and willful false presentation of a claim for benefits or payment under any federal insurance program. It was intentionally drafted by Congress as a broad provision, which essentially criminalizes the falsification of a medical record in support of a bill for services. It has not previously been used to prosecute an individual for the falsification of a medical record alone, albeit that is an accurate interpretation of the statute.

It is noteworthy that the prosecutor is not alleging that the medical record was falsified in an attempt to fraudulently bill the government for services not rendered or to otherwise personally financially benefit. That is not what this HIPAA provision requires—it only requires that a false statement was knowingly or willfully made in connection with services rendered that are paid for by a federal insurance program. Furthermore, the LPN is not being prosecuted for the resident's death. Instead, the prosecution centers on an act that few nurses previously would have known could result in potential incarceration—medical record falsification.

This prosecutor, who specializes in health care fraud, is admittedly using this case and this LPN as an example to deter medical record falsification. He admits that he has chosen this case to make a statement regarding what he perceived to be a significant problem. He maintains that medical records are "routinely falsified" and that if such falsifications are prosecuted as federal offenses, it will deter such behavior. The prosecution certainly serves as a significant reminder to all health care workers of the necessity to accurately and truthfully document in the patient's medical record.

Renee H. Martin is a health law associate at Wolf Block Schorr & Solis-Cohen, LLP, Philadelphia.


I am a nurse who actually did the falsifying of nurses notes and forged name on nurse note... I am not proud of this but do have reason even though wrong for doing!! I worked for a client that was a hoarder and very very dirty!!! Family was very dysfunctional and I was getting less and less hours due to client having me come in late and leave early!! I started filling slips out for time not there and signed her name!! I already lost my job and dont know what else will happen with this!! I an truly remorseful, not that i got "caught" but that i didnt go to my boss, who is a wonderful lady and talk to her! Was afraid of losing case and disappounting her didnt want to be a failure, wanted to be seen as being capable of handling the load given to me, which was extremely awful conditions!! Any advise or info would be appreciated!!

Chris Howell,  LPN,  HomeToStay,IncJanuary 17, 2015
Chambersburg, PA

A nurse acquisitioned my PHI (Protected Health Information)with malicious intent to use that PHI,and did use that PHI fraudulently. Specifically, the nurse did access my PHI, took that PHI into an emergency room waiting area, waived that PHI in the air and used it to continually and falsely verbally disseminate that I was HIV Positive. This was done by a nurse that works for the Veterans Administration. The incident has been reported to the Patient Advocate, Privacy Officer, Medical Director, Chief of Medicine, Health & Human Services, Office of Civil Rights, Office of the Inspector General, Veterans Health Administration Privacy Office, Virginia State Nursing Board and New York State Nursing Board. Anyone here getting the idea on how to deal with the Federal Government? Paperwork, paperwork, and then some paperwork. Do not let them deter you in your efforts if you believe you have been done wrong. You WILL have to work hard to stand up for yourself. However the truth never changes. It is always wise to keep all documentation and if you are like me, I write things out before I type it and I'm not even throwing away the trash! I am a veteran of the United States Army. Those jobs were built and designed upon the backs of veterans like myself and I simply say THIS IS MY VA!!!! If you cannot get do your job then get out and let someone who will enforce policy get in the driver's seat. I will not stop until criminal charges are brought against that nurse. I have walked in the shoes of a person with the HIV virus and it was a rude awakening. I am messed up psychologically and am in increased physical pain for a painful neurological disorder all because of that horrendous incident. Never give up and make them fix it! Veterans need to stand up against the VA. The VAMC's across america belong to us! We need to start acting like it!

Jae Johnson,  Retired,  Not applicableNovember 06, 2013
Portsmouth, VA

Maybe someone reading this can try and point me in the right direction. I have very obvious falsification of my medical records, which intailly started out with a nurse, then others went back and changed my medical records, which I luckily have the originals and started recording every medical appointment and daily harrasing phone calls, which I saved everything and copied it to CD's. Medical professionals have spent more time changing my records, trying to say I was a "NO-SHOW," for appointments, and have almost died laying in my own vomit, developed bleeding ulcers, living in fear, etc.,. and have been destroyed. I spent my life in the Army I love so much, I have never used any recrational drugs in my life and don't drink any sort of alcohol. I researched Falsification of medical records and found different cases where a local DA would charge people for knowingly wwriting false information and manipulating medical records. However, whenI called the DA's office they told me they protect the VA Medical Center and I guess people who work there are above the laws of this country. WHAT DO I DO?? I don't want money or sue anyone, I just want this blattant disregard for inhumane acts addressed, and make those accountable be responsible for breaking laws,which again the DA's office refused to even talk to me and told meto find a local attorney. I just don't understand how this can happen. Since returning to civilian life, i have learned one important thing, a FACT without any EVIDENCE is nothing more than a claim, which I have all the evidence the worst legal professional can clearly see my life has been destroyed. Any advice where to get started? Thanks and God Bless, Terry M Duncan, US Army Retired, Kingsport, TN

Terry Duncan,  Retired ArmyOctober 22, 2013
Kingsport, TN

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