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Is it legal to "fix" patient charts to meet Medicare requirements?

Friday April 13, 2012
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Dear Nancy,

I am an RN working on an inpatient hospice unit. This past week my employer became concerned that the nursing documentation on our units might not meet Medicare requirements. My employer directed my immediate manager to audit charts from March 1 of this year to the present and provided her with an audit tool. My manager was then directed to write out a list of what needs to be "fixed" or "added" to patient charts for that time period. She has given us all our "list" of documentation we are supposed to fix. I have several concerns about this. Is it legal?


Nancy Brent replies:

Dear Loraellyn,

Proper, accurate and complete nursing documentation is an important component of healthcare, including reimbursement and continued accreditation and certification from healthcare insurance programs like Medicare. No nurse or facility is perfect in its documentation, so there should be policies and procedures in place to help nursing staff document properly to begin with and rectify documentation that does not meet established requirements.

The policy (or an unwritten practice) should not condone falsification of any nursing documentation. Although you did not describe what "fixing" the documentation would consist of in your situation, "fixing"
never can include adding false information, false times of monitoring, false times of medication administration, etc.

Rather, the documentation policy should guide nursing staff how to, as examples, add accurate information inadvertently left out of a narrative or flow chart, (e.g., marking the addition "Late entry" with the accurate date and time or "Addition to entry of ______" with the accurate date and time). Additions to entries can be handled with an electronic health record as well, again pursuant to policies and the software used by the facility.
Remember that falsification of any entry in any record connected with a nurse's obligations as a healthcare provider, if proven, is grounds in most states for the board of nursing to take disciplinary action against the nurse. Also, it can be a basis for an allegation of unprofessional conduct against the nurse. As another concern, the Medicare and Medicaid Patient Protection Act of 1987 prohibits falsification of any record in order to obtain federal money through a benefit program. Doing so can result in a fine and criminal charges.

Clarify what it is you are being asked to "fix" with your CNO and nurse manager. More likely than not, the facility's request is that you do this to be consistent with its policies and with ethical and legal mandates.


Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.