Patient records are a crucial element of quality medical care. Nurses have a huge role in creating and maintaining accurate, updated patient records.
When records are accurate, patients receive the necessary treatment, and all the healthcare professionals providing their care know what is going on. The records will also help ensure serious mistakes don’t occur.
Unfortunately, mistakes happen. People get in a hurry. Nurses sometimes go back and add information to a record or make adjustments – but that can amount to falsification of a medical record and put their nursing license at risk.
Why does record falsification occur?
To some, the idea of falsifying patient records seems malicious, at best. However, this is not always the case.
For example, you may do this if you work a 12-hour or longer shift and want to go home. For example, you may not fill in everything related to the care you provided a patient or fill in loose information just to be done with your shift. In these cases, fatigue plays a huge role in what is happening.
In other situations, you may want to provide a patient with additional pain medication because they were having issues with their pain. You know they were not approved for more, and because of this, do not put it in their record. Unfortunately, while this may seem like a nice thing to do, it may lead to complications for the patient and your license.
Protecting your nursing license
If your nursing license is threatened, you have legal options. Knowing what these are will help you handle these situations.