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Legal / Ethics

Documentation: You’ve got a lot to lose

According to the Centers for Medicare & Medicaid Services, fraud is “the intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.” Misstatements or omissions found by auditors are not necessarily fraud. In fact, they’re usually errors. Errors aren’t deliberate; fraud is. Fraud requires the intent to mislead.

Then there are situations like this: Mary Jane Howe (not her real name) was certified in OB/GYN and had 18 years of experience working in labor and delivery. After a particularly busy night, she “approximated” the blood pressures for an eclampsic patient—graphing them “pretty close to what she remembered.” A random retrospective audit caught the discrepancies between the monitor’s readout and the charting.

Mary Jane documented what she did, but the charting was inaccurate and she knew it.

Other shades of gray

Sometimes nurses sign-off on medications that were given to, but not necessarily taken by, patients. This is not a mistake and may not be an error, but the nurse’s documentation could be incorrect.

Also, nursing environments are intense, and a patient may not receive his or her medications at all. And, in some organizations, if medications are late or missed, the nurse may be disciplined. Such policies may lead to nurses signing off on missed medications and disposing of them to avoid the discipline.

Other problems involve “early” documentation—indicating on a chart that you’ve done something before you actually do it. You may fully intend to do it but time, events, or both intervene—and the chart is falsified.

In “management-initiated” fraud, a supervisor tells nurses to fill in charts to satisfy regulatory surveyors, whether or not what they write is accurate. The intent is, at the very least, to mislead.

Honest mistakes and outright crimes

There are “innocent” mistakes, such as leaving an open space in your documentation or, for that matter, writing in an open space left by another nurse. In an Ohio case, a nursing student charted carefully, accurately, and fully, including blood pressures taken every 5 minutes, about an infiltration of Levophed that severely damaged a patient’s arm. The nursing student left one line between her charting and the night nurse’s charting. Above the nursing student’s charting, the day-shift charge nurse inserted “IV infiltrated and discontinued,” noted the time she wrote her note (end of shift), and signed it. A malpractice case ensued in which the patient claimed he’d been neglected all day long and the nursing student’s charting was deliberate fraud. Take-away point: Never leave a blank space when paper-charting, and never insert your documentation into a blank space left by another nurse.

Another honest mistake: A busy nurse doesn’t see a physician’s order for monitoring. However, the chart contains no incorrect information; the nurse doesn’t indicate monitoring was started. In this case, there’s no falsification—only error.

But where there’s intent to deceive, there’s fraud. In a Pennsylvania case, a licensed practical nurse (LPN) was prosecuted in federal court for taking a verbal order and transcribing it incorrectly, and then trying to cover it up. She was convicted for falsifying the record but not for the error. An error is not fraud. Fraud is fraud.

Rare cases of financially motivated fraud have occurred. In 2013, a registered nurse who fabricated nursing visit forms in connection with a $24 million home healthcare fraud conspiracy pled guilty for her role in the Medicare scheme. No one has any doubt about such cases. But many nurses may forget that deliberate omission or falsification on a chart is a felony and all felonies carry fines and a jail sentence. Any nurse convicted of a felony loses her license to practice. That’s a lot to lose: your job, your license, your career, and even your freedom.

Leah Curtin, RN, ScD(h), FAAN
Executive Editor, Professional Outreach
American Nurse Today


Campos NK. The legalities of nursing documentation. Men Nurs. 2010;40(1); 7-9.

Centers for Medicare and Medicaid. State Program Integrity Assessment. Glossary of terms. 2008. www.cms.gov/FraudAbuseforProfs/Downloads/FY08SPIAGlossary.pdf. Accessed July 5, 2014.

Hundemer v Sisters of Charity of Cincinnati. 22 Ohio App. 2d 119 (1969)

Martin RH. LPN faces criminal charges after covering up a medication transcription error. June 4, 2001. Advanced Health Network for Nurses. http://nursing.advanceweb.com/Article/Falsification-of-Medical-Records.aspx. Accessed July 5, 2014.

Med League support Services, Inc. Detecting tampering with medical records. www.medleague.com/services/medical-record-analysis/detecting-tampering-with-medical-records. Accessed July 5, 2014.

Moretti v. State Board of Pharmacy. 2 Pa. Cmwlth. 121, 277 A.2d (1971)

U.S. Department of Justice. Registered Nurse Pleads Guilty in Connection with Detroit Medicare Fraud Scheme. March 22, 2013. www.justice.gov/opa/pr/2013/March/13-crm-341.html. Accessed July 5, 2014.

3 thoughts on “Documentation: You’ve got a lot to lose”

  1. Karan Guetersloh says:

    A nurse recently documented in the medical record that I had not reported information to her that I had documented I had. I ended my notation with, “full report given to oncoming nurse”. I gave full report to the oncoming nurse. She was not the oncoming nurse. She was what my facility calls the support nurse. I have never given report to support nurse. Nor have I been told to. She did not listen to my report, was aware I was giving it. Documented “I read the previous notation from the previous nurse and this information was not given to me in report” . She did not specify that she was not the nurse who took over the patient, or that she was the support nurse for the day. It appears that I lied in my documentation. Which I did not.

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