Documentation plays a vital role in the delivery of medical services and achieving desired patient outcomes. One of the phenomena that may be disruptive to the integrity of medical documentation is concurrent therapy. Concurrent therapy, also known as “stacking,” happens when a medical worker administers treatment to a patient and then proceeds with initiating the treatment of another patient. At present, concurrent therapy is seen as an unsafe practice: the California Society for Respiratory Care (CSRC) calls for the discontinuation of practice that results in the negligence of patients. Today, advanced treatment methods allow for faster administration, therefore, eliminating the need for “stacking.” One of the pitfalls of concurrent therapy is the probability of making faulty, unintelligible records. Because a healthcare worker’s attention is divided, he or she might find it difficult to keep track of every action and document it with attention to detail.
In the state of California, as noted by the Respiratory Care Board (2011), falsifying medical records may result in revocation stayed with three years of probation. The disciplinary guidelines seem fair as falsifying records is an offense that may result in an adverse or even lethal outcome for a patient. By falsifying records, a medical professional violates all four principles of professional ethics: autonomy, benevolence, non-maleficence, and justice. At best, a healthcare worker who does this strips their patient of their right to manage their own health information. At worst, fabricating records directly endangers a patient’s life, especially when it comes to controlled substances.
The Board of Registered Nursing (the state of California) cites the Nursing Practice Act that implies similar disciplinary actions for falsifying medical records. Namely, this offense falls under the category of “Incompetence or gross negligence”: “To direct another or to personally falsify and/or make grossly incorrect […] entries […] not pertaining to controlled substances (State of California Board of Registered Nursing, 2003).” For doing this, a nurse may be facing revocation stayed with three years probation. There is a distinct section addressing fabricating records pertaining to controlled substances: “Conviction of a criminal offense involving […] the possession of or falsification of a record pertaining to narcotics or dangerous drugs (State of California Board of Registered Nursing, 2003).” The punishment is the same: revocation stayed with three years probation.
Incomplete, erroneous, or fraudulent documentation is seen as inherently negative as it can lead to adverse consequences, including unfavorable patient outcomes. In her article, McDowell (2018) discusses the issues that stem from faulty medical documentation. The author opines that while “falsifying medical records” might sound sinister and even intimidating, it is an umbrella term for a number of activities some of which do not include a fraudulent intent. Regardless of the intent, a medical professional who tampers with records may be facing legal charges. In some states, falsifying medical records is a criminal offense while in others, it is considered to be a forgery (McDowell, 2018). A common motivation for fabricating records is trying to escape a medical malpractice suit. In this case, a healthcare worker tampers with medical data to make it look as if they have not done anything wrong. If purposeful falsification becomes discovered, a healthcare worker will lose any credibility in court (McDowell, 2018). Other ramifications for fraudulent documentation range from a reprimand to a fine to license suspension or even loss of a license.
References
California Society for Respiratory Care. (2011). 2015 CSRC position statement pertaining to concurrent therapy. Web.
McDowell, R. K. (2018). What are the consequences of falsifying medical records? Web.
Respiratory Care Board. (2011). Disciplinary guidelines. Web.
State of California Board of Registered Nursing. (2003). Recommended guidelines for disciplinary orders and conditions of probation. Web.