Altered charting

  1. :stone Hi I am new to this forum and I have come across a situation at work that I wanted to get more input on. Here's the situation: I had to give pt. 2 units of PRBC's. I did the pre vitals and they were all fine. Including a normal temp of 98.8 orally. 15 min. vitals were also normal. I then was ending my shift and passed this patient on to another RN to finish the transfusion and also complete the next. When I came back to work the next day it was reported to me that the pt had become confused in the night. I happened to glance at the blood vitals with the transfusions and noted that my charting of the temp had been altered to include 98.8 AX and that the post transfusion temp was 100.9 Ax and the box next to the transfusion reaction was check marked as None. I notified my supervisor of the change and made her a copy. I am not sure what will happen next with this particular nurse, if anything and am wondering what you all feel the appropriate steps should be for her. This nurse is notoriously known on our floor as being able to get away with A LOT. I would like to be prepared. Thank you.
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  2. 9 Comments

  3. by   gwenith
    If she is notorious for getting away with a lot then probably nothing will happen you however have to keep in mind that you might have made an enemy and sorry to repeat this but

    document document document

    keep running notes of conversations with her and issues. Could be that she will do nothing and that she was "trying you on" to see if she COULD get away with anything. Sometimes too the reaction you get is not immediated - it is two or three weeks down the track when you feel the knife in your back.

    Good luck and keep us posted - a lot of people here have been through situations with difficult co-worker so you usually can get some advice on how to deal with them.
  4. by   sharann
    So does this mean that by altering it, she was avoiding dealing with a serious reaction to the blood? I hope not for her patients sake. You did the right thing by reporting this.
  5. by   nurjco
    I believe this is exactly what was happening. It meant less work for her by altering the charting.

    Quote from sharann
    So does this mean that by altering it, she was avoiding dealing with a serious reaction to the blood? I hope not for her patients sake. You did the right thing by reporting this.
  6. by   luanne123
    I would contact the hospital attorney.
  7. by   redwinggirlie
    I copy the transfusion documents and have the charge nurse initial them. Mostly, they end up shoved in the depths of my locker, but I know they are there. Good luck to you.
  8. by   redwinggirlie
    By the by, how can you alter a carbon copy? Does your facility use carbons? Where do you chart your vitals?
  9. by   sharann
    Quote from redwinggirlie
    By the by, how can you alter a carbon copy? Does your facility use carbons? Where do you chart your vitals?
    This just reminded me that we have 3 copies of the transfusion record(cc's).
    The white(top)copy stays in the pts chart, the yellow copy goes to blood bank with the empty blood bag(all bags go back, reaction or not), and a third copy pink, goes to medical review or somewhere. So if something is missing, such as a signature or set of vitals, they can trace it back to the original person/s who signed the paperwork.If you have this, then see if the blood bank has a diifernt temp(your original) 98.8
  10. by   nurjco
    Our facility has 2 copies. One goes in the chart and the other goes to the blood bank when the transfusion is done. But all copies stay on the floor until the blood is complete therefore the alteration was written on both of the copies when the post transfusion vitals were taken. I believe when these vitals were taken, it was noted that there was an increased temp and by changing my oral temp to an axillary temp it wouldn't have been that much of a change and wouldn't be considered a possible blood reaction. The story gets worse because this particular nurse then didn't give the second unit of blood and passed it on to the next shift to give and ultimately the patient ended up having a classic blood reaction to the next unit. Temp increased even further, confusion, and back pain.
  11. by   sjoe
    Quote from redwinggirlie
    I copy the transfusion documents and have the charge nurse initial them. Mostly, they end up shoved in the depths of my locker, but I know they are there. Good luck to you.
    My suggestion: Take these documents, including your notes, HOME and keep them in a safe place. If it suits them, any employer can have you escorted out by security with no notice and THEY will clean out your locker at their convenience later on--the locker belongs to them, after all, as do these documents. You need to protect yourself.

    (And don't any of you bother to flame me about HIPPA, etc. Should charges present themselves about this, and other incidents, HIPPA will be the least of red's problems.)
    Last edit by sjoe on Mar 20, '04

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