Altering a patients chart

[sunkissed75]

Last night while I was on AllNurses, I came across a thread about a family suing a hospital. Someone had posted that they had experienced the same kind of thing except "thankfully they were given a chance to tune up the charting before the medical records were released to the families lawyer" . I was just wondering if this is common. I only ask because I am in school right now and we are learning that one of the most critical aspects of nursing is proper documentation. Altering a patients record is a criminal offence and charting care that wasn't done is fraud. What's the point in being accurate if someone can go and alter the records anyway. It just seems very wrong and very unethical. If you have any thoughts on this topic please share. I am very interested now it what other people's opinions are on this.

Thanks!

[Ayvah, RN]

The charting system we use (Meditech) you can change the date/time stamp so you can chart something later and have it appear as if it was charted a previous day.

Click on history and then you will see each entry, the date/time it was entered for, and the actual date/time it was entered.

[sunkissed75, CNA]

it is a criminal offense, but i know there are facilities that encourage cleaning up charts. one in particular, a few years ago where a patient died in a local rehab due to staff negligence. the chart was pulled and the nurse in question was asked to improve her charting before the lawyers got ahold of it. in facilities like this one, they can smell a lawsuit coming and will do everything they can to avoid becoming the losing party. it's easier to "clean up the charting" if it's a paper system rather than computer entries.

yes, it is wrong and illegal and all that.......

all i can say is, wait until you're out of school and on the floor. i've been told quite a few times to "just make it look good!" (meaning the mar's and charts) by my superiors.

thanks for all the replies...definately stuff we don't learn in school!! i am very interested in bringing this subject up tomarrow with my teacher and classmates...wonder where it will lead!