Nursing homes and other health care facilities use clinical records to track whether their patients have received the required care, to monitor changes in patient condition, and to evaluate the effectiveness of the care being provided. By documenting care given, health care providers can make informed decisions regarding the patients’ medical needs.
The federal government requires nursing facilities to retain complete clinical record information. The facility must safeguard clinical record against loss, destruction, or unauthorized use.
Among other things, clinical record information includes documentation of the plan of care and services provided. The standard of care requires that clinical records accurately reflect:
- Who created the records;
- When the records were created; and
- What care was given.
Accurate, thorough and timely entries in a patient’s chart are critical to ensure that the care providers have accurate information about the patient’s condition and treatment – from one shift to another, from one day to the next. If those records are false or altered then the ability to honestly evaluate the care given is compromised.
Unfortunately, clinical records in nursing homes are altered or falsified all too often. This can be for a number of reasons. The facility may be trying to complete the chart. Other times, it can be an effort to maximize reimbursement. It can also be an effort to cover up improper care.
Whatever the reason, falsifying medical records is wrong.
Medical records often provide the basis for the prosecution and defense of a case involving medical negligence. If records have been falsified, they also prove that the medical provider is untrustworthy. False records hide the truth.
For the other parts in this 4-part series, click on the following:
Uncovering the truth is the mission of the Kosieradzki • Smith Law Firm when representing clients harmed by nursing homes and other care facilities that fail to provide proper care. As a Minnesota district court judge recently found, sometimes those care providers attempt to cover up their wrongdoing by falsifying patient records. The Kosieradzki Smith Law Firm has the experience and tools needed to uncover the truth. If you believe your loved one has been wronged by a care provider, take action and contact the Kosieradzki • Smith Law Firm online or call us toll-free at (877) 552-2873 to set up a no-cost, no-obligation consultation.