Documenting for someone else

[EquusAnonymous]

Sigh...I'm being asked by my DON to document immunizations given by MAs who are no longer with our company and who failed to document and submit them. I am completly uncomfortable with this. I was told today that if I don't know if it was given I need to look at the doctors note to determine if it was given, if I'm still not satisfied I need to contact the parents of the patients and ask if the patient received the vaccinations. She told me all I have to do is document that it was given and also document what ever MA I presume gave it, gave it. The rational is that the patient needs to have a correct MR so that they don't end up having to get the same immunization. The problem is I can't guarentee what MA actually gave the vaccination as there is no documentation to tell me-I can tell who roomed the patient but I can't tell if another MA jumped in and gave the immunization and I can't be 100% sure the immunization was actually given in the first place. A majority of the patients will have a form scanned in the chart with an order/document that states that at that visit with those imz ordered they are now up to date on their IMZs-but again there is no signature by anyone that actually would be giving the vaccines, only the doctors signature at the bottom that should signafy that they ordered those vaccines and they were given. I can contact the parents but so many parents can't tell you how many immunizations their child got on any given day (and I'm looking at a 5 month time span) let alone what they were.

Does anyone have any advice on what to do or resources that I can go to?

Thank you!

[icuRNmaggie, BSN, RN]

Which brings up a very good point.

If you are terminated for refusing to comply with this unreasonable request and you are aware that the documentation was completed by another, CMS might be interested in knowing about that illegal and unprofessional activity.

and the state health department and the CDC

If this goes back for five months, how long have you worked there?

I am certainly no expert on childhood immunizations, but it seems to me that the prudent thing for the clinic to do would be to draw titers on every child immunized there whose records are incomplete.

[mama.RN]

I won't repeat what's already been said so eloquently by other posters, but just wanted to chime in to say, DO NOT UNDER ANY CIRCUMSTANCES DO THIS.

[JustBeachyNurse, LPN]

and the state health department and the CDC

If this goes back for five months, how long have you worked there?

I am certainly no expert on childhood immunizations, but it seems to me that the prudent thing for the clinic to do would be to draw titers on every child immunized there whose records are incomplete.

Something similar happened in my area with false vaccination documentation and also expired vaccines. Many people lost their licenses, at least one child was seriously, and permanently harmed because parents thought their child was vaccinated against varicella and MMR. CDC, Dept of Health, Medicaid services, prosecutors office and a host of acronyms were involved those who received citations were added to the OIG list for insurance/ Medicaid fraud.

Yeah, Id say perhaps find a new job and consider an anonymous complaint to corporate compliance or the health dept. Don't falsify documentation. It's likely an insurance claim got flagged or an audit is pending if they use the vaccines for children program and they are backtracking on documentation

[Lev, MSN, RN, NP]

OP, any updates?

[ixchel]

Mom calling your office: "I'm pregnant and my child's classmate has chicken pox. Did my son get that vaccine?"

Person at your office who answers the phone: "I see here in your records he did get it."

One month later, her baby is stillborn.

THIS IS SO INCREDIBLY NOT WORTH THE RISKS.

I'd rather give already vaccinated kids another round of vaccines than know the above scenario is possible. Heck, not losing my license is kinda nice, too.

What scares me, OP, is that if you say no, who might say yes? I really think previous suggestions of calling some outside agencies (CMS for instance) might be a good idea if you suspect your DON makes this happen without your help.

[EquusAnonymous]

Sorry for the delayed reply I've been going through a lot of health issues and haven't had time to get back. Thank you everyone for all your input. I actually put in my resignation before any of this occured and am on my last week. This issue being one of the many reason I no longer feel comfortable working here.

I feel better knowing I was not alone in thinking this was a terrible idea. Tomorrow I will be forwarding her the list of patients that can't be completed notifying her that I will not be documenting for anyone else when I was not there to ensure that it was given. I plan on giving the suggestion of having the providers-who had ordered the vaccines, providing they are sure of their documentation that do not mention vaccines rejected, not given ect ect record that the vaccines were given as they are the only other person who can actually attest to the patients receiving the vacccines.

To everyone that has given a senario-those exact senario's are exactly why I was not comfortable with it. I honestly have no idea why things were not documented-it could have been a simple mistake where the MA for got or accidently missed the documentation. Or it could have been not documented on purpose due to it not actually having been given.

Sigh...thanks again everyone for your words of wisdom and support. :)

[icuRNmaggie, BSN, RN]

Smart move.

Please make sure that the Medical Director is fully aware of the problems within this organization. He is ultimately responsible and has a right to know. Do not be surprised if they try to sweep it under the rug. But you will have the peace of mind of knowing that you tried to conduct yourself ethically.

Save those emails just in case. BCC to your private email account.