Manager wants me to alter documentation on expired patient

[All4NursingRN]

I recently took care of a very critical patient who was not expected to survive (septic shock, DIC) who was to receive multiple units of blood products. The patient expired before the transfusion was complete so on the form I checked off the 3/4 box as that the transfusion was about 75% complete and indicated that patient expired before transfusion could be completed.

my manager does chart review and approached me and says that it was inappropriate to chart this and that I should have wrote all vital signs as "0" on the form and wants me to retrieve the chart from medical records and change it.

i recently took a course in critical care nursing and nursing documentation and approached the speaker who is a legal nurse consultant and has sat on numerous legal cases and asked her opinion.

she said that there is nothing wrong with what I wrote, it is accurate and I cannot document v/s as "0" if I coded the patient because not v/s were taken! It was a code! She was adamant I do not alter my documentation.

how do I now approach my manager?

[MelEpiRN]

"Avoid this in the future by placing a line through boxes that can't be completed in the usual way and write something to the effect, "CPR in progress, please refer to resuscitation record."

It's true that we don't alter our records, but being accurate and clear in the first place is important."

YES. Exactly what JKL33 said. As a PI reviewer, this is really what we're looking for. Clear documentation. If boxes are blank, we HAVE to go with the assumption that proper monitoring wasn't done. I'm not dumb, I understand that (for instance) you can't do XYZ while the patient is in MRI, but if you leave blanks, an outside auditor or lawyer doesn't know that. Time stamps/documentation do not always match up, and occasionally paper records end up in other patients charts or just disappear forever so it's always helpful to line through the blanks and add supporting info elsewhere if necessary.

[Julius Seizure]

I swear she still could not understand why I would not have put vitals on that damn paper. Weeks later she was still asking me why I hadn't put pre-transfusion vitals on the sheet, I asked if she wanted me to count his heart rate with compressions or without...

But are they really "pre-transfusion" vitals if there never was a transfusion?

[All4NursingRN]

Thanks texasholdem, the patient was extemely critical and it was explained to the family that he more than likely would not survive, he was on several vasopressors and had received about 13 liters of fluid blouses. His vital 15 minute into transfusion were within his typical limits at the time, no fever spike and all other vitals consistent to his pre-transfusion state.

Another reason why I do not want to write in his vitals as "0" is because I too believe that makes it seem as though there was some transfusion reaction that occurred instead of the possibility that the patient succumbed to septic shock.

He was in pretty bad shape, found down at home and received cpr in the field, we resuscitated him for about 10 min and when we reached the family via telephone they said to stop cpr immediately, so I believe they understood that his condition was grave.

The fact that your patient died while receiving a blood product raises many questions. Was it the first unit? Was the code witnessed? What was the infusion rate? Did you follow hospital policy for blood product transfusions? Was there a trend that a reasonable and prudent nurse would have recognized? Did you disconnect the blood before, during, or after the code? What other medications were running at the time? etc. and so forth

[All4NursingRN]

Thanks!, at the time I did chart that the transfusion was not completed and the reason why in my documentation but I have a feeling my manager did not fully review the documentation, it does seem as though the lab flagged the form due to the missing vitals, referred it to him, so he just wants me to fill in the blanks.

Avoid this in the future by placing a line through boxes that can't be completed in the usual way and write something to the effect, "CPR in progress, please refer to resuscitation record."

It's true that we don't alter our records, but being accurate and clear in the first place is important. I once had someone just leave blank the "rhythm" section on a resuscitation record because "they had no rhythm." I discovered this at the end of the code (i.e. immediately). I asked the person to "please fill in 'asystole' - that is the rhythm." Person refused to "alter" the document. Well - - I guess it's more ethical that it looks like no one even made effort to monitor the rhythm the entire time??

Blanks that are usually filled in on every patient become significant when they're not filled in and there is no clear explanation.

I would not put zeros in the boxes. That is also not accurate. I would tell manager that you will write a note in the chart if she insists but will not fill in zeros. You can write a note, "Addendum 10/25/17: Please refer to resuscitation record for vital signs during the transfusion of PRBC unit # ____________." That's all I personally would be willing to do.

[All4NursingRN]

Oh wow this is very similar to my situation except I don't know how my manager will react to me not taking his suggestion if "0" as the patients vitals.

I had a very similar situation a few years ago. A patient of mine was ordered 4 units of FFP. Unit #3 was finished, took vitals, docs came in so I waited a few moments to hang unit #4, docs left the room(maybe 10 minutes later), I was spiking the bag for #4 and heard the patient gasp. No pulse, no respirations, dead as dead could be. We got a pulse back, moved him to ICU where he died about 2 hours later. My manager just could not understand why the FFP was hanging, but not infused and why there were no vitals. She kept calling and calling about it, finally the ICU manager got sick of the "but the box must be checked" nonsense, grabbed a different blood bank sheet and wrote DEAD in big red letters across the vitals section(not the sheet going in the patient's chart, he was just proving a point) and gave it to my manager. I swear she still could not understand why I would not have put vitals on that damn paper. Weeks later she was still asking me why I hadn't put pre-transfusion vitals on the sheet, I asked if she wanted me to count his heart rate with compressions or without...

All that to say, do not change your charting. The patient died, "0" is not going to change anything.

[JKL33]

Thanks!, at the time I did chart that the transfusion was not completed and the reason why in my documentation but I have a feeling my manager did not fully review the documentation, it does seem as though the lab flagged the form due to the missing vitals, referred it to him, so he just wants me to fill in the blanks.

Inform your manager that you are unable to place zeros in the boxes because that is inaccurate, but that you are willing to strike through the boxes. Ask if that is adequate since all the other documentation (resuscitation documentation, etc) is already in place. Let's assume (hope) he will agree.

Get the transfusion record, strike through the empty boxes, and write (on that same page itself): "Strike-through of empty boxes addended on 10/25/17 as instructed by _____________." Signature and time/date.

[LovingLife123]

We have to have all of our boxes checked as well and they will write an ers on any that are not. I was going to ask when you discontinuedcthe transfusion? Also if you are in an icu and have continuous monitoring you should just be able to pull up the vitals. Except maybe temp which I would have put something to the effect of N/A.

If the transfusion ran during the code until the patient died, then your respirations, heart rate, and bp would be zero. If you disconnected it prior to starting compressions, I would have pulled the vitals up on the monitor.

I don't see that they are asking you to do anything illegal, just to complete the paperwork.

[jodispamodi]

I worked for a company that asked me to change documents/assessments (one placed asked me to do this to make non-eligible patients look eligible). This is how I handled it, if I felt my documentation was correct. I stated I would stand on my documentation, if the manager (or whoever was requesting the change) wanted to they could go and change it themselves. IF I agreed my documentation wasnt clear then I would change it and put in a note stating error in documentation noted by blah blah corrected per their request.

I suspect with your DIC patient they are just CYA'ing for the transfusion.

[dishes, BSN, RN]

Speak to your risk manager, it may seem harmless to chart in a deceased patient's chart after the fact, but lawyers can make this type of cya charting look suspicious in a court case. If you are not willing to call your risk manager or if your manager is not willing to arrange a meeting with the risk manager and yourself, ask your manager to send you their request to alter the chart via email (explain that you need to see it in writing). Then forward the email to the risk manager and ask for clarification on the legal ramifications of altering documentation.

[Meriwhen, ASN, BSN, MSN, RN]

No no no no no.

If you didn't take these vitals, then don't chart these vitals. If your manager wants them to read 0, then let him chart them and put his *** and license on the line. You need to protect YOUR license.

[palli]

I would not change anything, and honestly I would be a litle worried about someone going in and changing it on me......

just sayin, if he is desparate enough to ask you to do it, and you refuse...it might get done without you knowing...

[Sunshine716]

It has always been my understanding that after 24 hours has passed you cannot add an addendum to the patient's chart or make any changes without any exceptions. Am I wrong in thinking this? If so, what she is asking you to do is not legal for a nurse to do, period.