Medical records are regarded as being very personal documents. They have many legal and ethical issues surrounding them aimed at keeping them accurate, such as need for appropriate storage and the degree of third-party access to them. As a medical professional in charge of making the entries, sometimes you may be tempted to falsify your client’s medical records. This is malpractice and it comes with serious consequences.
Spoliation of evidence is the alteration or destruction of evidence to falsify a record. When you deliberately alter medical records to give false evidence before the court of law, you may be penalized by the court for perjury and spoliation. In most jurisdictions, it is a cause of action for tort, and you may be charged with negligence or statutory tort. In that case, you will have to compensate the client (plaintiff) for damages.
Once the court of law has proved that as a medical practitioner you have the tendency to falsify your patients’ medical records, the consequences may be loss of license to practice, or loss of hospital privileges, such as loss of accreditation or eligibility to participate in federal reimbursement programs.
Falsification of medical records is a felony. When you falsify medical records, knowingly and unlawfully for the purpose of obtaining a favor, such when a patient gives you bribes you to falsify his medical record, you may be charged in court for felony. The potential penalty for this is usually a maximum of five years in prison, or a $250,000 fine.
If you falsify a client’s records, the court will require you to give an explanation for this offense. When found guilty of this offense by deliberately altering or falsifying the records, the court will consequently grant punitive damages. Punitive damages are meant to discourage malpractice. Although it is not intended to compensate the plaintiff like most compensatory damages for civil suits, you will be required to pay the plaintiff for emotional distress he went through and his medical costs.
As a medical practitioner, falsifying medical practitioner may raise questions about the quality of care that you render to patients. This may have a serious impact on you, causing the general public to lose trust in your integrity. In the end, patients may be hesitant about seeking treatment from your facility.
- Kentucky Legislature: Criminal Falsification of a Medical Record -- Penalties
- Med League: Spoliation of Evidence: Detecting Tampering with Medical Records
- Physician Law; Altering Medical Records: What Not To Do When Being Audited By Medicare; Todd Rodriguez; Aug. 2008
- University of Tennessee Health Science Center; Medical Records; Dec. 2007
- American Board of Legal Medicine; Alteration, Destruction, or Loss of Records; S.Sandy Sanbar;