PHARMACIST STEVE

Falsifying a patient’s medical record-such as entering a lower blood pressure reading than what was actually measured during an office visit-is both illegal and unethical.

We all have to keep in mind what we are often told by politicians and bureaucrats: “NO ONE IS ABOVE THE LAW ..” but it seems like that is only half of an accurate saying, it should be finished with “.. except for those who are in charge of enforcing our laws…”

Of course, I am not going to “bet the farm” on some oversight entity – medical licensing board, insurance company, Joint Commission, or corporate employer to take action against a practitioner who is caught falsifying a pt’s medical records, but one can only hope!

Legal Status

• Falsification Defined: Falsifying medical records involves intentionally altering, fabricating, or omitting information in a patient’s health documentation with the intent to deceive or mislead. This includes inaccurately noting vital signs like blood pressure14.

• Criminal Offense: Such actions are considered a crime in most jurisdictions. Penalties can include fines, imprisonment, and loss of professional licensure. For example, in some states, falsifying medical records can be prosecuted as a felony, carrying potential jail time and significant fines245.

• Professional Consequences: Healthcare providers who falsify records risk disciplinary action by licensing boards, including suspension or revocation of their license to practice124.

Ethical and Professional Implications

• Breach of Trust: Falsifying records undermines the trust between patients and healthcare providers and can compromise patient safety, leading to inappropriate or harmful medical decisions14.

• Malpractice Liability: If falsification is discovered, it can severely undermine the credibility of the provider and may increase liability in malpractice claims, as altered records are often used as evidence in legal proceedings12.

Case Example

A federal investigation found that a provider knowingly entered false blood pressure readings (e.g., 120/80) into patient records during virtual visits. This was determined to be a violation of ethical standards and documentation policy, creating a potential threat to patient care, even if no immediate harm was identified3.

Summary Table

In summary: Intentionally entering a lower blood pressure reading than was actually taken is illegal, unethical, and can result in criminal charges, civil liability, and professional discipline1245. Accurate documentation is a legal and ethical obligation for all healthcare professionals.