falsifying medical records

  1. 0
    I am so angry right now, I don't know where to start. Anyway here it goes. I work in the emergency department of a major trauma center. Last week while checking an admission chart for completeness prior to transferring a patient from the emergency room to the medical floor, I discovered that my manager had written my name (suggesting that the orders had been carried out) on a whole page of admission orders. Orders by the way which are to be carried out on the med-surg floor. When I confronted her about it. She replied that she "writes" her charge nurses' names on all orders that are not signed off.
    As with most areas of nursing, staffing is short, however I feel that not only is the manager putting my integrity on the line but also jeopardizing the patient. The patient may suffer because once these orders are noted or signed off it is assumed that they are done.
    Additionally, I receive charts on a daily basis with notes telling me that I need to write a note on the chart or sign orders off. Often time I have not even seen the person this chart belongs to. Most nights I work with half the staff (or less) than we are budgeted for which is well under the number needed to safely, adequately and effectively care for the patients we receive.
    I know there is something horribly wrong with this. I don't know what to do or who to talk to. Anytime I suggest that I am not going to write anything on a chart of a patient that I have not seen, it is suggested that I am the one with the problem. To add to the insult the doctors have been allowed to discharge patients and the nurses are expected to write a discharge note on a chart of a patient that they did not send home.
    I am open to all suggestions.
    Thanks ...
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  4. 17 Comments so far...

  5. 0
    Well, for starters, your manager cannot sign your name to anything legally. I would personally have a cow right on the spot if I found out that somebody else was using my name for anything. There is no excuse or reason. And as you noted, how confusing. Don't you just wonder how many orders may have been missed because of this practice! If I received a chart on a patient whom I had not seen, I would put a sticky stating I had not seen this patient. And with big, innocent eyes when confronted, I would say "Well I can't legally chart on a patient I haven't seen, can I?" That's just what I would do/have done, and sometimes I find myself not working in these places anymore. But I still have my license. Panther, this is wrong from start to finish. Surely, your hospital employs legal counsel. I suggest your next step is to talk to that person. Let us know what happens. Your instincts and knowledge are right on target.
  6. 1
    Panther
    I cannot believe someone actually has the nerve to sign YOUR name to anything and justify it when confronted. I would not touch that with someone else's ten foot pole. My gosh, what if something grossly negligent happened or didn't happen that was ordered, your name is on it, and if you rebuted with " My charge nurse said she routinely signed my name to charts that orders had not been signed off on." It would still come back on you by " Well why did you allow this to happen." I would go to her again, then she has to have a supervisor and I would go immediately to him/her, then if no results, they too have a supervisor and I'd be paying them a visit too. Protect your license..bottom line. You can find another short staffed, place to work like a dog, and get taken advantage of but you cannot find another license to practice your livelihood once it is permantnently revoked for someones elses gross neglience. If it is so important that all the charts she checks have signatures why doesn't she make sure the orders have been taken off and carried out then sign HER name.
    Be careful and keep us posted
    lorrie
    afterthought: that's fraud. end of story. it is scary to know people like that even practice.
    canoehead likes this.
  7. 2
    I am currently on contract in a busy ED as well and I can understand your frustration with incomplete charts. My first piece of advice is for you to ask your manager what his/her rationale is for signing the charts with another individual's name without knowledge or consent? Ask her if she has researched the legality of this practice and encourage her to seek counsel from risk management. Signing someone elses name to a legal document is patently illegal. She needs to be informed so she can change her practice. You should advise her that she needs to bring the charts to you to document your work and your work only.

    As busy as it gets in the ED, the first thing I do when I come in is to check the charts of the patients to which I am assigned. I have made it very clear to my colleagues that I will not accept an empty chart and I will not take report on them until the charts are up to date. It is working great for me so far. I also work with LPNs/Medics in the ED and I make it clear that their work must be verified by me. With an unfamiliar staff member, I delegate data collection only. With a seasoned staff member with whom I have worked and am comfortable, I delegate activities to the fullest extent of their legal capabilities. And of course, I must document my signature stating that the care rendered was appropriate.

    I hope this helps you.

    regards
    Chas
    SilentfadesRPA and LPNnowRN like this.
  8. 0
    Panter,
    Everyone has given you good advice so far, I would add that seeking a new place of employment may be in the cards. If you feel you must do something to stop this activity I would put all my concerns in writting and send to all possible admin types including hosp. risk manager and atty. If those actions didn't result in positive resolution of the problem then I would consider contacting the State Board of Nursing and asking them to look into the situation.
    I notice you areposting from CA, if you are represented by CNA, or any other union I would also contact them.

    [This message has been edited by ocankhe (edited January 18, 2001).]
  9. 0
    Since what she did is both fraudulent and illegal, AND puts YOUR license also on the line, I'd IMMEDIATELY take this to management and I'd DOCUMENT I did it. IF it happens again, I'm hit the FIRST GOOD lawyer I could find!!

    Man I don't miss that mess at all....

    Linda/CMAS, BS, RN
    BizNurse@satx.rr.com
  10. 3
    Many thanks for your reply. I was able to talk to risk management today. Risk management agreed that there is something wrong with this picture. I was given information on how to pursue the issues mentioned.
    Thanks again. I needed to be reassured that my elevator goes all the way to the top.
    ARTPOPIST, Cinquefoil, and Batman25 like this.
  11. 0
    Good work! Thanks for the update.
  12. 1
    Report her to the administration and tell her if she does it again then report her to the State Board. It is illegal and put you at a tremendous liabilty.
    SilentfadesRPA likes this.
  13. 0
    Originally posted by deLadyPanther:
    I am so angry right now, I don't know where to start. Anyway here it goes. I work in the emergency department of a major trauma center. Last week while checking an admission chart for completeness prior to transferring a patient from the emergency room to the medical floor, I discovered that my manager had written my name (suggesting that the orders had been carried out) on a whole page of admission orders. Orders by the way which are to be carried out on the med-surg floor. When I confronted her about it. She replied that she "writes" her charge nurses' names on all orders that are not signed off.
    As with most areas of nursing, staffing is short, however I feel that not only is the manager putting my integrity on the line but also jeopardizing the patient. The patient may suffer because once these orders are noted or signed off it is assumed that they are done.
    Additionally, I receive charts on a daily basis with notes telling me that I need to write a note on the chart or sign orders off. Often time I have not even seen the person this chart belongs to. Most nights I work with half the staff (or less) than we are budgeted for which is well under the number needed to safely, adequately and effectively care for the patients we receive.
    I know there is something horribly wrong with this. I don't know what to do or who to talk to. Anytime I suggest that I am not going to write anything on a chart of a patient that I have not seen, it is suggested that I am the one with the problem. To add to the insult the doctors have been allowed to discharge patients and the nurses are expected to write a discharge note on a chart of a patient that they did not send home.
    I am open to all suggestions.
    Thanks ...
    Hello frustrated I feel your pain I am in the same exact position as you and I understand completely what you are going through I too work at a level one trauma center and I know how caotic it can be. but there is one thing I need cleared up you stated that she writes your name and not signs it correct. If so she has not forged your signature. But it does mean that you in some way had contact with that patient. I too walk into work finding charts that belong to patients from days ago and all of a sudden it it my responsibility to sign them out. I too took the argumentive approach and all this does is make you feel inadequate since you still have to sign the chart out. My solution, I take all the charts and add my own addendum, Found chart, signed out, no contact with patient. I believe in doing this I can cover myself for any liability that may come with that particular chart. As far as your manager is conserned I would again voice my displeasure and request that if she wants me to sign a chart out then she should bring me the chart and atleast I will have some knowledge of what i'm doing should I have to go to court for one reason or another. Don't refuse to sign out the charts unless your hospital has a policy on it stating that you don't have to sign it out. Maybe this will atleast stop her from putting your name on a chart that you have no idea of whats going on with it, it will be signed out and you can sleep easier at night. If this doesn't help I would take it to her supervisor. It worked for me. The other thing I did was when I came in, in the morning if any charts were lying around I would give them to the off going charge nurse for her to put her initials on, why should I have all the fun right. I hope this helps you


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