Re: Altering a patients chart
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.
Altering a patients chart
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