Altering a patients chart

**pagandeva2000** · Jul 06, 2009, 12:16 PM

Re: Altering a patients chart

Originally Posted by YankeeHater

What about if you come back the next day and chart something you forgot to put in the computer the day before on a pt that is still there? The computer doesn't allow you to "clearly mark" the addendum as such. it looks the same as any other documentation. You just change the documentation time and it's like you are going back in time... or is it? Is there a problem with doing that?

If there is an area to free text, that is the place where I type in capital letters :Late Entry related to 01/01/2009 12:05pm...

**pagandeva2000** · Jul 06, 2009, 12:19 PM

Re: Altering a patients chart

Originally Posted by DolceVita

Don't be fooled. You will find that there is still an electronic "footprint" showing when the data was in fact added.

I agree. It may show for the person entering that this was information that was added, but, when medical records pulls it out, it will show each time the person entered, which is not in the vision of the person documenting.

We have a feature called "supplemental" or "correction" where, I have added supplemental information that I forgot to chart in the first place, but I am comfortable saying in a court situation that I added this supplemental information.

Ayvah · Jul 06, 2009, 12:27 PM

Re: Altering a patients chart

Originally Posted by loriangel14

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.

studentnurse75 · Jul 06, 2009, 06:36 PM

Re: Altering a patients chart

Originally Posted by AnnemRN

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.

Originally Posted by Grasshopper01

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

Originally Posted by Grasshopper01

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!

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Altering a patients chart

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