The falsification of documentation in nursing homes is prevalent. The chart is under the control and sole possession of the nursing home. They can add, delete, modify, insert, or print whatever information they want to create a false narrative. We see it happen all the time. Well, the police finally arrested someone.
Law enforcement charged a licensed practical nurse working with five counts of Intentionally Placing False Information in a Medical Record. The Michigan attorney general’s office found Jennifer Porter “intentionally altered medication administration records to hide the fact that certain doses of medication were not accounted for.” Each count is a five-year felony.
Why is Reliable Documentation Important?
Accurate and complete documentation in a nursing home clinical setting is necessary for several reasons:
- Legal requirement: Documentation is required by law and is used as evidence in case of a legal dispute.
- Patient care: Documentation helps to ensure that all aspects of a patient’s care are recorded, including their medical history, treatments, and response to care. This information is crucial for continuity of care and safe treatment planning.
- Communication: Documentation helps to communicate important information between healthcare providers, including physicians, nurses, and other members of the interdisciplinary care team.
- Compliance: Documentation is also used to demonstrate compliance with regulatory standards and accreditation requirements.
- Reimbursement: Documentation is also used for billing purposes and is often required for insurance reimbursement.
In summary, accurate and complete documentation is essential for ensuring safe and effective patient care, regulatory compliance, and effective communication between healthcare providers.