Altering a patients chart

Nurses General Nursing

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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!

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Specializes in LTC, Dementia/Alzheimer's.

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.

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Specializes in Hospice, LTC, Rehab, Home Health.

Not sure what is meant by "tuning up" While late entries and addenda to charting are legal, most lawsuits happen long after I would be comfortable adding one. Have gone back the next day and added an addendum about something I had forgotten about that had happened just before the end of my shift. Also late entries and addenda MUST be clearly marked as such. Hope this is helpful.

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Have gone back the next day and added an addendum about something I had forgotten about that had happened just before the end of my shift. Also late entries and addenda MUST be clearly marked as such. Hope this is helpful.

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?

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Specializes in Cardiac, ER.
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?

Any computer charting system I've ever used clearly marks the date and time at which you chart something. If I forget to chart something on tuesday and the pt is still there on thursday and I add to tuesday's charting it clearly shows that I added info on thursday about something that happened on tuesday.

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Specializes in Home health.
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!

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.

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I am a legal nurse consultant/expert witness. As long as a let entry is clearly labeled as such, it is ok. And this is done often. BUt if adding information after the shift is happening and it is not being labeled as a late entry, that is fraudlent charting.

I was in a deposition for a case that I was consulting on, and the hospital's attorney asked me what information in the chart indicated that the patient was dehydrated. Using the chart that I had been provided by the hospital attorney at the deposition, I referred to the date at the top of the page for an I/O record and assessment and began looking for the supportive data that I had found in the chart earlier, and couldn't find it on the copy that I had. The attorney who hired me said "Wait a minute" and began to compare the chart that the hospital attorney had provided to him that morning to the copy of the chart that he had. What happened here, in a nutshell, was that my attorney got an "older" copy of the chart from the hospital's medical records department and that copy had been altered without noting late entries. We were provided the "new" copy of the chart, I'm sure by mistake, by the hospital attorney, but we had brought both versions with us. Bottom line, we caught chart tampering quite by accident, and the hospital lost the case.

So, the take home lesson here is to chart late entries as such. There is no harm in a late entry, but you HAVE to label it as such, or you look as though you are covering up something.

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Specializes in Acute Care, Rehab, Palliative.

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.

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I know of two incidents where a chart was altered, and we had the earlier chart as proof that it was done.

In one case, it involved a lawsuit, and since the records had been altered, the patient got a bigger judgment.

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Specializes in IMCU.
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.

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

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Specializes in Community Health, Med-Surg, Home Health.
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...

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Specializes in Community Health, Med-Surg, Home Health.
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.

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