Backdating the Periodontal Chart
Nina has worked for three months at a practice where Dr. Cole owns the records. She completed SRP on 12 teeth for a patient with 5–6 mm pockets. After the visit, Dr. Cole tells Nina to change the probing depths in the EHR to 7–8 mm, add a note that bone loss is evident, and backdate the note to the day before the visit. He says this will support a higher-level periodontal maintenance code and a claim to the patient’s insurer. Nina knows the original measurements were 5–6 mm and that no bone loss was documented. Dr. Cole says, “Everyone does this; it’s just paperwork.” Nina is uncomfortable but worries about losing her job. The office manager has already submitted the claim.
1. What legal and professional problems are raised by Dr. Cole’s instruction? Identify the specific categories of misconduct.
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The instruction is misconduct. Changing probing depths, adding a bone-loss finding that was not documented, and backdating a note are record falsification. Submitting a claim based on those changes is false billing and potentially insurance fraud. These are categories of unprofessional conduct and can also trigger civil or criminal exposure. The statement that everyone does this is not a defense. The original measurements and the absence of a bone-loss note matter because the record must accurately reflect what was observed and done.
2. What should Nina do now, including with the patient record and the already-submitted claim?
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Nina should refuse to alter the original record. She may write a factual addendum describing the actual measurements and the request, but she must not backdate or delete the original entry. She should preserve her own copy of the relevant records in the manner allowed by law and consult an attorney or the Board about reporting. The practice must correct the already-submitted claim to the insurer; Nina should put her concern in writing to Dr. Cole and the office manager and keep a copy. If the dentist retaliates, she should document that too.
3. What are the possible consequences for Nina if she complies, and what protections or reporting obligations should she consider?
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If she complies, Nina could face Board discipline for falsification and fraud, civil penalties, suspension or revocation, and possible criminal referral. Her license is hers, not the employer’s. She should not sign or submit anything she knows is false. She should consider whether Pennsylvania reporting obligations for licensees apply and seek confidential legal advice before reporting. She should also document the request, her refusal, and any corrective steps taken. Protecting the record and not participating in the false claim are the priority.