Quote from JulieCVICURN
But it WAS wrong. Maybe you would have written the same thing on every patient, but what you did makes the documentation look as if it's been falsified. If I were a Joint Commission surveyor, I'd have been all over your facility if I found some glaring evidence of negligent charting like that.
So what would have appeared to be falsified?
I would guess that HAND written charting would be easier to falsify than copies that are signed. If you really wanted to falsify something, all you have to do is toss the original, get a new sheet and fill in what you need. Original handwriting is very detectable.
You can't do that with a copy.
The purpose of charting is accurate information...as long as the patient identifier is there, the information is accurate and bears an original signature, it should be rendered as valid.
Electronic charting is no different...the same thing appears on the screen over and over again and I can go back and change any of it I want...what we PRINT is in the chart..our printed copies DO NOT show that I made ANY corrections.