Recently a patient and family member questioned me what their physician was saying about the case, we reviewed the notes together with the permission of the patient.

Both the patient and the family member who intentionally stayed at the patient's side to act as an advocate denied that the physician had been in to the patient's room that day even though there was a complete head to toe assessment with problem list and plan.

The patient now stated that since I am aware that there is documentation that they say is fraudulent I am being held accountable by them to report the incident, which after confer with the house supervisor on a weekend I reported to the unit manager.

I have been questioned multiple times regarding this incident and the issue continues to be the discussion with the family not the fraudulent documentation of the MD. I feel like my job is in jeopardy now even after a conversation with my manager.

Will human resources or any other pathway be helpful in preserving my position. I will be completing my BSN in December and will have more flexibility after completion of my degree to change facilities.

Any suggestions will be greatly appreciated.

Are you sure you didn't violate policy by showing the patient and family members their records? I have never worked anywhere where this would be acceptable practice. The patients need to make formal requests through medical records, or access a system online as setup by the hospital. It is totally inappropriate for you to show a patient a physician's progress notes.

I have always referred these people to an administrator who makes arrangements for the physician to be present to "prevent any misunderstandings."

Your facility is worried about being reported for fraud hence the interest in your conversation with the family, whom you allowed to manipulate you into showing them the chart and then reporting a physician.

HR exists to protect the facility not the employee. They will not help you in this situation. You are a potential whistleblower. Expect to be suspended discredited then terminated. Realistically you need to line up another job now.

Call your malpractice carrier for legal advice.

Although I agree with the last two posts about the legalities of this situation, I want to voice a personal opinion about this. Being that I'm in the Healthcare field, I know that if i am the patient there are continuous progress notes documented in my chart, and it is MY chart after all, why shouldn't I be allowed to see it? If there's a full head to toe assessment in there from a doctor I never met, but will be billed for seeing, I'd raise hell too.

I may be playing devil's advocate here, but a few years ago I had a PCP that I didn't care much for. She worked within the same system I did, and I had full legal rights to access my chart there. I found all sorts of documentation from her on symptoms I never said that I had, and she charted I denied symptoms that I had actually come in with. It infuriated me, and I'm glad that I discovered this, in order to find a new doctor.

I'm glad I've never worked at any of these places where inpatients can only get information about their care by making an appointment with medical records. I'm not sure how that meets the legal requirement that patients have timely access to all information related to their care, much less the ethical requirement that should be preventing nurses from tolerating such a rule.

You let that family manipulate and use you for whatever their agenda is! How do you know for 100 percent sure that there was not a visit that day? MDs can make very short visits and patients are often medicated,sick and lose track of the day and time and even time of day. They can even copy and paste plans of treatment,problem lists and other date with just a few clicks of the mouse. I would have never got cozy and shared that chart. I would have referred them up the chain of command and let them deal with their perceived problem. Does this family have an agenda to sue or create problems? I guarantee if they do they will not be helping you pay your bills if you lose your job.

There are so many facilities that have patient portals that give patient's complete access to their own charts. With that being said, sometimes (and I am not suggesting this is correct) MD's use the last office/ER visit as a template of the initial assessment to create the problem list, as this is why they were admitted to begin with. If that makes sense.

I always defer to charge nurse and/or case management to review a case with a patient's family. They can get the correct paperwork/access for the PATIENT to decide what is seen/not seen, what to discuss and the like. Even if the patient "gives permission" it is hard to tell what the intent of the patient really is, and sometimes that means keeping the peace.

The only thing you can do is first off, you have no idea the intent, the action or inaction, the "story" behind any part of the chart that is not your own. So you can not say for certain that any part of the chart is accurate but your own entries. You should have a union rep involved. You should call your malpractice insurance.

Been old and jaded and at this a long time, I can guess the following: Family is uptight that Gram is in the hospital, as they are concerned that the social security check is gonna stop coming. That everything they are focused on inheriting is going down the tubes to the nursing home if it comes to that. That the dumb doc has not a CLUE what they are talking about, and they are nit picking to manipulate what they see as fact. Which is THEY are bringing gram home on the feeding tube or that hubby needs SSI payments, or that Mom of COURSE is going to sue for workman's comp... And the dynamics are such that the second cousin by marriage is just as invested as the daughter who is a gold digger rotten person who weaseled her way into this by setting up shop at gram's house....the NERVE!! And her no good kids who are mooching.....

You get the picture. Never, ever get all involved in family dynamics. Team sport, use your resources, so that there is more than you getting caught up in the information swap meet.

Call your malpractice carrier. Call your union rep. And going forward, always defer this type of stuff to your charge nurse for further interventions.

I'm glad I've never worked at any of these places where inpatients can only get information about their care by making an appointment with medical records. I'm not sure how that meets the legal requirement that patients have timely access to all information related to their care, much less the ethical requirement that should be preventing nurses from tolerating such a rule.

There's nothing unethical about it. the system is designed so that only people who should have access to the chart, do. There are things that keep me up, but this sure isn't one of them.

How can you be held accountable for what a Physician wrote?

You can only be held accountable for your own documentation-am I missing something?

PS keep your own notes on this incident-Time and dates etc

*I* would not have filed an incident report based on hearsay from the patient/family. Instead, I would have given them the resources and contact information to allow them to file a report themselves.

Some facilities/organizations allow people full, "real time" access to their records. Many don't, and have policies that people wanting access to their records need to follow a particular procedure. I've never worked anywhere where a nurse could just pull out a chart and sit down with the client/family to go through the chart (and I would not be willing to do that, personally, even in a facility that allowed that -- I would refer them to the physician). I can certainly see why the interaction with management is about your chart review with the family rather than the concerns about the physician falsifying documentation, and I have a feeling this is going to turn out badly for you (not that I'm hoping it will, but ...). What does the facility policy say about clients reviewing their records? Did you check the policy before you gave them the chart? If you violated the facility's policy, you're not going to have much with which to defend yourself. Best wishes --

You let that family manipulate and use you for whatever their agenda is! How do you know for 100 percent sure that there was not a visit that day? MDs can make very short visits and patients are often medicated,sick and lose track of the day and time and even time of day. They can even copy and paste plans of treatment,problem lists and other date with just a few clicks of the mouse. I would have never got cozy and shared that chart. I would have referred them up the chain of command and let them deal with their perceived problem. Does this family have an agenda to sue or create problems? I guarantee if they do they will not be helping you pay your bills if you lose your job.

I've had many situations over the years in which clients stated that they hadn't been seen by the physician when I knew for a fact that they had -- I had walked them down to the physician's office (this was in inpatient psychiatric settings) and watched them go through the door and sit down with the psychiatrist (I didn't know what they and the psychiatrist had talked about, but I darned sure knew that they had seen the psychiatrist), or I had walked the physician to the room and watched the physican enter the room to see them, or seen the physican come out of the room and ask me a question about the person -- and, then, later in the day, people would claim that they hadn't seen the physician that day. It happens, folks. People are medicated, drowsy, they get their days mixed up, whatever. I would never assume that, just because some said s/he wasn't seen by the physician that day, that s/he actually wasn't seen.