Maybe you have to tell a teenage girl that she is pregnant, and she begs you not to put it in her medical record so her parents won’t find out about it. Although you assure her that she has privacy rights, she knows her parents will coerce her into giving them access to that information or already have convinced her to sign such documents. She tearfully tells you that she will make an appointment at a free-standing clinic and just wants to put the whole thing behind her.
You might consider doing exactly what the young woman asks because you think that an official record of the test you administered would permanently affect her life. There are many situations in which nurses may face patients who want information excluded from their records or added to it. Sometimes these people have compelling reasons.
No matter the circumstance, including anything false in a medical record could put your license at risk.
Medical record fraud is a crime in California
Under California state law, it is a misdemeanor offense for someone to fraudulently alter medical records. Fraudulent alterations could include the exclusion/removal of information or the intentional addition of inaccurate information.
Regardless of what a patient wants people to know, having a thorough and accurate medical record is crucial not only for their current health but also for their future medical care. One of your many duties as a nurse is to accurately record information and provide the right details to the physician treating the patient.
Although you may feel an emotional connection with the patient and have a lot of compassion for a difficult situation in which they find themselves, agreeing to manipulate someone’s medical record could cost you your job and your profession.
You could lose your freedom, job or nursing license for lying
If it comes to light somehow that you intentionally altered medical records or recorded inaccurate information in them, you could face prosecution. Once you have a criminal record, the California Board of Registered Nursing will likely learn about the issue the next time you renew your license.
Even if you avoid criminal charges, the patient involved or the people at your practice who discover the inaccurate record-keeping could cause an investigation that costs you your job or report the matter to the licensing board, triggering a disciplinary review. Knowing the state laws that apply to the medical profession can help you avoid mistakes that could cost you your nursing license.