Our small hospital recently acquired an electronic system and a terrible one at that; it is cheap and incomplete. We have acquired a great deal of incomplete charting, which will create deficits in reimbursements, primarily in med-reconciliation. We all were given a list of random patients seen in the last three months and told to sign onto the system and chart the med-reconciliation aspect of the program. Many of these patients were not physically cared for by me and I was not physically present in the facility. My question is if I am being asked to commit fraud or chart illegally on patients for when I did not provide care.
Dear Nancy replies:
The directive you received concerning medication reconciliation raises many legal questions concerning the documentation you are asked to do. How can you enter information in the EMR about a certain day or a specific patient care issue if you were not on duty that day? Unless you had some responsibility for the patients you did not care for, how can you in good faith document an entry for those patients either?
It is important that you contact a nurse attorney or other attorney in your state who can provide you with specific advice about what you should do with this request and how it would be best handled. He or she may also suggest reporting this directive to appropriate outside agencies depending on the specifics of the situation and of your facility.
You should seek legal advice as soon as possible in order to protect yourself. At a minimum, the knowing falsification of a patient’s medical record, or any record used in your practice, is grounds for the state board of nursing to discipline you.