A member asked:

Could the creation of an office visit entry in a patient's chart for a visit that never occurred, w/o documentation, be considered falsification?

2 doctors weighed in across 2 answers

If there was verbal, text, or telemedicine, or zoom contact and even a third party involved, than it should be documented on patients chart. The entry should state that where contact took place with patient, whether in or out of office. Falsification is no contact of any means possible.

Answered 4/19/2023

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Dr. Silviu Pasniciuc answered

Specializes in Internal Medicine

Not necessarily, it has to do with the EMR being used inadvertently labeling as entries sometimes attempts to review chart or inadvertently opening a future visit. Providers can document at any given time non direct care, communication with other family members or consultants, review of tests and that will automatically create a new entry, sometimes improperly labeled as a visit.

Answered 4/19/2023

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