Ethical dilemma r/t documentation

[Murse901, MSN, RN]

I am a new nurse and I work as an LPN in a LTC facility. A few days ago, we had a readmit. With any admit or readmit, we have to do an admission assessment (I'm sure this is all common knowledge for the most part, just setting up the story). The admission assessment is a form separate from the nurse's admission note, although both contain much of the same information. But the admission form has a number of things that don't go in the NN's like elopement risk assessment, fall precaution assessment, etc.

ANYway, I did the admission assessment on my pt along with a few other documents (pain assessment form r/t pressure ulcer and another pain assessment form later in the evening r/t new pain). I turned these assessment forms in to the DoN per protocol.

At some point between then and today, the forms were lost. Bear in mind that A) these are all legal documents, and B) admission assessment forms must be completed within 16 hours of admission per state regulation.

So, today, the DoN and corporate QA nurse ask me to rewrite the lost admission assessment and pain assessment. The DoN admitted at this time that she knew that I already did them, because she had them in her possession at some point, but that they were lost and couldn't be found anywhere (they searched through all the charts).

At that time, I said that I would rewrite the documents later in my shift. It didn't occur to me until several hours later that I would be a complete freaking moron to rewrite legal documents and date them with a date other than today's date.

By the time I figured that out, the DoN and QA nurse were gone, so I couldn't discuss the issue with them.

Am I wrong in thinking that this would be a huge violation and that I am basically hanging myself if I rewrite these documents? All I can think is that if the state were to audit the facility and were to find the original misplaced documents, that would pretty much buy me a one-way ticket to a State Board of Nursing's review of my license.

The chances of the state auditing the facility and finding the misplaced documents are very slim, but I still feel that I am jeopardizing my license by doing this. Not to mention that it's just plain unethical to even ask me to do that, and that it's not my responsibility to come up with these lost documents when the DoN admitted to having them in her possession.

On the other hand, if I don't rewrite the documents, I could be fired. TN is an at-will employment state, so they could fire me without giving a reason. But, I think that it would be better to have to go out looking for another job than to not be able to work at all due to not having a license.

I don't really know what to do here. Well, I do know what to do, but I'm concerned about my financial stability. I worked too hard for my license to have it snatched away due my covering up for someone else's carelessness.

Anyone else have thoughts on this? Am I overreacting by thinking that it's wrong for them to even ask me to do this?

[All_Smiles_RN]

I say don't do it. Don't jeapordize your license for this organization.

[wjf00]

The law must be quite different in CA. LVN's in CA 'collect data' only an RN can 'assess'. Perhaps you could refer the DON to the RN's assessment... if there is one.

[NurseCard, ADN]

Yikes... you are really in between a rock and a hard place here, huh? Well, I think it was totally wrong for the DoN to ask you to rewrite the documents; she is obviously trying to use you to cover up her own big mistake. I also vote that you not do what they've asked you to do. If they still try to make you rewrite the docs and make threats if you don't... have your resignation in your hand.

[burn out]

I would redo them as asked with todays date and time, then accompany them with an incident/safety report (which I have photocopied before turning them in) about the two previously written but missing documents. You have to cya.

[morte, LPN, LVN]

I would redo them as asked with todays date and time, then accompany them with an incident/safety report (which I have photocopied before turning them in) about the two previously written but missing documents. You have to cya.

in my state it is 24 hours....make sure that 16 is actually the law in your state....if so, i would do the work, dated for the date it was actually done, and document that it was a replacement for that which was misplaced.

[DDRN4me]

I would agree that you should not put the original date on the document. Use the current date and add addendum such as "late entry" or "modified" or "recopied" this will document that you obtained the information at the correct time but will also cover you for not doing the documentation late. I also agree that an incident report stating that original data was misplaced (use neutral language so as not to place actual blame). good luck!! I would also let the DON know that you were uncomfortable and perhaps suggest a better way to manage the paper trail .

[canoehead, BSN, RN]

It's not an issue if someone wants you to rewrite anything. Just note that you are rewriting, and what happened to the original. The issue would be if they asked you to falsify the rewrite- that would be something to stand your ground on.

[txspadequeenRN, BSN, RN]

It is different in LTC.

The law must be quite different in CA. LVN's in CA 'collect data' only an RN can 'assess'. Perhaps you could refer the DON to the RN's assessment... if there is one.

[starbin, BSN, RN]

As a LTC care nurse, I have been requested to rewrite, rephrase and sometimes even add few sentences to the previously written notes..the notes they were written months ago. These activies are specially intensified when it is time for annual State survey. I refused to rewrite and next day I found out that someone else had scribbled my part. I didn't say a word, it is not my name/ signature ....why bother. I have even witnessed some notes being lost, missing........after a couple of months..because the note shows that the facility failed to maintain the standard of care in one way or the other. The unit managers and MDS co-ordinators and all those heads spend more time in reviewing and fixing the charts than doing anything else. Sometimes we joke- "we have more meetings in here than in white House". They lack adequate staffing and overload the nurses with paperwork and hire more people to fix the documents so that they will not loose the license to run the nursing home.

[NurseCard, ADN]

I wonder if there's some way that you can consult with someone who specializes in legal nursing? To find out exactly what you should do? I mean, rewriting the document way after the fact seems wrong to me too, but maybe if you follow it up in ways suggested here, like with an incident report or whatever... then it would be fine. I dunno; I've never had anything like what you described happen to me before.

[CoffeeRTC, BSN, RN]

Sounds like the DON lost them? Instead of giving the forms to the DON,why cant they just check the chart for them. Passing papers around like that just makes things easier to get lost.

You can fill out the assessment sheets again. Just date it like you would do a late entry. ex. 2-1-2007, 11am. Late entry for 1-30-2007, 7-3shift. Unable to locate previous admit assement done on 1-30-2007.........