Is this considered falsification?

Nurses General Nursing

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Hi, if a nurse edits a note to include an addendum as a correction to a note made earlier, is that considered falsification? The original note was not deleted but an addendum was added. The original note contained a set of vitals. The addendum contained a correction to the vitals. Also, the addendum was made 48 hours later. Would this be an issue?

Sour Lemon

5,016 Posts

Hi, if a nurse edits a note to include an addendum as a correction to a note made earlier, is that considered falsification?

...only if it's false.

MommyRN89

15 Posts

No it was the accurate data. A typo existed in the original note.

Specializes in NICU, ICU, PICU, Academia.

That is not falsification- it is clarification.

MommyRN89

15 Posts

Thank you. Does it matter if the note was titled "late entry" or not? It was just titled as an addendum and timed and dated for the date of the addendum

Crush

462 Posts

Specializes in Case manager, float pool, and more.

It should state late entry w/time and date. If entered after 24 hrs I believe it should also include reason such as you mentioned about it being a correction, etc.

Susie2310

2,121 Posts

It should state Late Entry with the date and time.

MommyRN89

15 Posts

There was a reason but it didn't specifically state late entry

Tenebrae, BSN, RN

1,951 Posts

Specializes in Mental Health, Gerontology, Palliative.

Generally if i'm having to write an amendment/addition to a previous note i'll write something like "11/12/17 0815, following note written in retrospect for 10/12/17 am shift"

Its only falsification if its incorrect information

Specializes in Critical care.

So just out of curiosity .... did you write the note? Or is this a witch hunt, and you are after the person who did? Something seems off.

Julius Seizure

1 Article; 2,282 Posts

Specializes in Pediatric Critical Care.

Addendum, late entry....same difference. As long as whatever is written is true and that it is clear that it was written at a different (later) time/date than whatever it is clarifying.

Meriwhen, ASN, BSN, MSN, RN

4 Articles; 7,907 Posts

Specializes in Psych ICU, addictions.
Hi, if a nurse edits a note to include an addendum as a correction to a note made earlier, is that considered falsification? The original note was not deleted but an addendum was added. The original note contained a set of vitals. The addendum contained a correction to the vitals. Also, the addendum was made 48 hours later. Would this be an issue?

Presuming the information being added in the addendum is correct...no, it's not falsification. I do it: sometimes the finger hits "save" before I've had a chance to fully proofread my note, so I have to go back in and put the correct info. I prefer addending as opposed to uncharting the note and then writing a whole new one.

As far as the timing, the EMR should automatically show the date/time of the addendum as well as the fact that it's an addendum, so it won't be a big secret that information was added and when. However, if you wish, you could add "Late Entry." It's not really necessary IMO, but if it makes you happy--or if it's facility policy--then do it.

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