Is it legal to rewrite nursing notes 3 months later?

Nurses General Nursing

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I just received an email from the manager of my home health care agency. She discussed how my notes were audited and because i scribbled out a word and wrote "omit" on top of it that i was going to have to rewrite the entire note. There are 16 dates (over a length of 3 months) that I had done this on (because i thought it was ok to do) and the notes are atleast a full page if not 2 or 3 pages. Am i legally allowed to re write an ENTIRE note 3 months later. I understand now that "omit" on top of the scribbles does not cut it and we are only allowed to put a line through our error, but to re write 16 notes because of one word scribbled out on the notes seems a bit much. I suggested initialing the scribble but she said that wont cut it. HELP!!!

no you can't. At least not using that date from three months earlier. You can however go into the chart and put a late entry in dated for the date you do the entry- (current) and then add whatever additional info you have to. However if you go to court it looks bad, especially if you are qualifying your earlier note, like you're trying to cover your butt, which you are.:)

All of us silently looked on in dumbfounded amazement at such a glaring example of how not to do it, stunned at the lengths that some people would go to, in order to cover up their errors.

Amen....This sums up this entire debate. If I had a choice between having a jury perceive me as a sloppy nurse cause some coffee spilled on one of my notes..or being perceived as obstructing justice for altering legal evidence...I'm gonna pick the lesser of the two evils and take my chances rather then commit a CRIME. Yes, it is illegal to Tamper with evidence..so you dont under any circumstances want to do anything to give the impression that you did that...

First off, they can do forensic testing to determine when your note was written..so if you rewrote it 3 months later...and did not include the old copies..they can tell it was a rewrite. Well what happened to the originals? A jury may think you are trying to hide something.

Both facts I recently read in a documentation CEU that I took.

I am here tonight because my office was pushing us to do rewrites for coffee stains..so i was wondering what this community has to say about that. I guess if it happens during your shift and you start your note over right away, it would not be too bad.

Specializes in Peds Medical Floor.

I would only rewrite them if the original notes were kept AND you wrote today's date and started your note with on 11/5/2011 at 2305 (or whatever time and date the original notes were from). Don't let it look like the new notes are the originals.

Hey sblanchard1983, i had a question for you about how you became an independent nurse provider with masshealth. I saw your post yesterday but that discussion is closed. Thanks girl.

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