[nrsnangel]

Hi! I am a new LPN and have come across a strange problem at my job. We had a resident die last week. She was a diabetic, grossly obese, in renal failure and non-compliant with all nursing and doctors orders. The night nurse is the only nurse on(this is a nursing home)and does get busy with rounds. She had a nurses note on this resident("Sally") at 0100 that had Sally "up in her w/c watching tv and eating a snack". Her next entry was at 0430. At this time she found Sally "in her bed, unresponsive--no BP, no P, and no R". She called the doc who had her call the mortician etc.The next afternoon, I was asked to rewrite my nurses note, verbatim,onto a new page. I was unsure why I was asked to do this until I read the following page--the night nurse had made entries every 2 hours exactly from the time I left at 2300 until the time she found Sally dead and thru the end of her shift. She was covering her butt making it look as though she had made rounds consistently and each entry had a comment about how Sally was "in no apparent distress"--until she was found dead. Should I have rewritten my entry? I don't feel right about doing so. I feel like I am deceiving the family. I did make a copy of th original entries and kept that at home. What should I do??

[canoehead]

You could refuse to recopy it and be perfectly justified- but then possibly in trouble for insubordination...I don't know.

The other alternative would be to recopy as asked, but at the beginning of your note write "recopied from original on (date and time) per request of ____"

Legally you must note when you recopy a page that is not the original note, or when you write a late entry, and they recommend you state why you recopied...like "recopied on ___date from original because of coffee spill. " Of course they recommend you keep the original with the chart even if it is illegible so coverups exactly like they are trying to accomplish at your facility do not occur. I wonder where the original from your chart will end up.

[Fran-RN]

I would not change my charting. but the night nurse could possibly have checked on this resident more frequently than the original documentation showed. we do not always document every time we check on a resident as every one knows. If you are caring for 20-40 residents this is impossible. I work nights at a LTC facility and my residents are seen at least every 2 hrs but sometimes they are not charted on for a week except for flow sheets.

[WeSignificants]

If I had been in charge, I might have requested the noc nurse put in any late entries that were valid. She may very well have seen the resident in the missing time frame but if nothing was unusual may not have charted it.

[CoachCathy]

A better idea than to try to back track like your facility did is to "freeze" the chart after an unexpected death. We do that at our facility - we use a dummy nurses note for the charge nurse that was caring for the resident to chart on. At the end of the shift, she can review it to make sure that she has included everything. Then, she copies everything into the chart.

[jevans]

Gosh
I can not believe that you have been requested to rewrite your entry. You were not at faulty it was the night nurse's responsibility to ensure that her documentation was up to date before going off shift.
Obviously you do not write everything that you do throughout a shift and I can appreciate that time constraints could have contributed to her failure to document but she can write after your entry in retrospect.
Are you a member of a nursing union or official body ? if in doubt you can always ask for advice.
Canoe head's response is extremely valid when ever you have been requested to alter documentation you should state at whose request and why
Not so long ago I had made a clinical judgement, documented it but did not give my rationale. One of my staff addressed this with our manager a few days later and I then stated in the notes
" written in retrospect for [date and time] due to the concerns of colleaques, then gave my rationale. On discussion with our senior nurse this was the correct course of action.
Do not forget that you could become implicated if this was investigated
Hope this helps
j

[sassynurse78]

I am confused, why would have to rewrite your nursing note? Why would " Sally's" death be unexpected? If the fact that she was in renal failure is not enough to justify her death, then hopefully the nurses have charted on her non-compliance before, which should also cover it. I have had residents die unexpectedly many times but since we are talking about geriatric resdients then really it is not unexpected is it? I do not understand why the night nurse felt like this person needed to be charted on every two hours. And why there would be anything wrong with your entry.

[susanmary]

Originally posted by WeSignificants
If I had been in charge, I might have requested the noc nurse put in any late entries that were valid. She may very well have seen the resident in the missing time frame but if nothing was unusual may not have charted it.

I agree. The charge nurse or the noc nurse should have written a late entry note. They passed the buck onto you. There are more ethical places to work ... I'd look elsewhere. Sue