What constitutes falsifying documentation?

[physioex]

I know of a nurse who put her initials on a flow sheet for her entire shift ahead of time. She was in orientation and was never told by preceptor or coworkers that this constituted falsification of documentation. She was terminated for doing it on 3 occasions. She never falsified assessments, v/s, outcomes, plans of care, only initialed her flowsheet for her entire shift before it was actually that time. She'd been complaining of coworkers being viscious, making false accusations, and tattle telling about non-nursing related matters. She'd had felt like she was being watched closely to get fired and now it came true!! Can she really be terminated for this? Is this really falsification if she did the actually charting at the real time, but only initialed ahead of time?

[Jory, MSN, APRN, CNM]

It is falsification and she didn't need her preceptor to tell her that it was wrong...because in nursing school you learn that you never, ever write something that didn't happen and if it's not in writing, it didn't happen. These are standard NCLEX questions.

I cannot tell you how many times my assignment changed throughout the evening....so how did she know that her patient was even going to be alive in 6 hours?

She didn't....that is why she was fired.

To be honest..if a person is that lazy they shouldn't be a nurse.

[nursel56]

Your questions are really in the realm of legal advice, and could very likely depend on your state law. Your best course of action is to keep trying to contact your BON there, or possibly pertinent legal advise from someone here:

The American Association of Nurse Attorneys

As an aside, I wonder what the intended purpose of altering the medical record was?

Your boss just doesn't want to deal with the inconvenience it seems, but she is skating on very thin ice should someone from your local regulatory body do a chart audit. I don't think whether you are an LPN or an RN has anything to do with it as the law applies to all nurses.

[Jory, MSN, APRN, CNM]

Your questions are really in the realm of legal advice, and could very likely depend on your state law. Your best course of action is to keep trying to contact your BON there, or possibly pertinent legal advise from someone here:

The American Association of Nurse Attorneys

As an aside, I wonder what the intended purpose of altering the medical record was?

Your boss just doesn't want to deal with the inconvenience it seems, but she is skating on very thin ice should someone from your local regulatory body do a chart audit. I don't think whether you are an LPN or an RN has anything to do with it as the law applies to all nurses.

Actually, it isn't legal advice and what is considered false documentation, does not vary by state.

We all learn about documentation in nursing school and this is reinforced when you get to the hospital. You are also given a login and password to all computers and told very specifically, if you let someone else chart/access the computer under your name or forget to log out, you are held liable for any charting and/or HIPAA violations that occur under your name. You even sign a paper stating that you agree to it.

To me, this is not complicated or legal advice...it is simple common sense.

You only chart what you did and what you personally witnessed. Period.

You don't chart ahead, you date and time according to facility policy and if someone said, "Oh yeah, I gave your patient morphine while you were gone to lunch...he was due...can you chart that for me?" Uh no...you gave the med...I didn't see you give the med...thanks for the help but you need to chart it.

I trust absolutely no one when it comes to charting...not even my best friend at work.

Charting anything but what YOU did and what YOU PERSONALLY witnessed is false charting.

It doesn't get any more simple than that.

[VictoriaGayle]

That is falsifying, and a hue liability. If the place was under inspection and they decided to look at her charts do you really think they would let that slide? You are not to sign anything ahead of time. What if someone decided to write in one of the blanks she had already signed?

Just initialling something really doesn't save that much time. I think others have pointed out she might have to leave mid shift, or someone else might need to take her patient. Her initials are already there. They can't exactly mark them out. And her initials on something that was filled out when she isn't even in the building is DEFINATELY flasification.

Its better safe than sorry. Always follow protocol. Even if she wasn't told durring orientation not to do it that way, was she told to do it that way? Probably not. Even if she was, don't they drill this kind of thing into you at nursing school? She knew this wasn't how she was suppose to fill out the paper work, even if she didn't think it was falsification.

On orientation did they actually see her doing this? Did she ask if it was ok? I dont see what orientation had to do with it unless she was told to do it that way or they clearly stated that it was ok. But even then, she is still responsible for her own actons.

[nursel56]

note: to be clear here I'm referring to the post from AKNorton on Sept 2 of this year,not resurrecting a thread where there is a two year gap with no messages.

Actually, it isn't legal advice and what is considered false documentation, does not vary by state.

We all learn about documentation in nursing school and this is reinforced when you get to the hospital. You are also given a login and password to all computers and told very specifically, if you let someone else chart/access the computer under your name or forget to log out, you are held liable for any charting and/or HIPAA violations that occur under your name. You even sign a paper stating that you agree to it.

To me, this is not complicated or legal advice...it is simple common sense.

You only chart what you did and what you personally witnessed. Period.

I guess it would be common sense if we were discussing HIPAA and your facility's protocols for EMR and signing a document intended to absolve them of culpability should there be an illegal breach in the system. Thanks for the quick refresher course on documentation, though.

In this particular case we have one nurse who crossed out another nurse's entries on a paper MAR and supplied a different time and a manager who is unresponsive to the OP's concerns. Whether we're merely talking about a discussion rather than advice is hair-splitting and runs the risk of straying in that realm, which is against our Terms of Service here.

How would you answer these questions and not have it be legal advise?

I'm quite certain the alteration is not only unethical but criminal. What about falsification though? Is that a crime as well? Is it a separate crime?

I have copies of the MARs that she falsified and altered. Could this put me in violation of HIPPA laws?

And also I'm wondering if the same laws apply to all Nurses regardless of the setting?

If it's against state law to alter charting entries, is this law going to apply regardless of the health care setting we work in or regardless of the employer?

Do the same laws apply to LPNs?

[Asystole RN]

note: to be clear here I'm referring to the post from AKNorton on Sept 2 of this year,not resurrecting a thread where there is a two year gap with no messages.

I guess it would be common sense if we were discussing HIPAA and your facility's protocols for EMR and signing a document intended to absolve them of culpability should there be an illegal breach in the system. Thanks for the quick refresher course on documentation, though.

In this particular case we have one nurse who crossed out another nurse's entries on a paper MAR and supplied a different time and a manager who is unresponsive to the OP's concerns. Whether we're merely talking about a discussion rather than advice is hair-splitting and runs the risk of straying in that realm, which is against our Terms of Service here.

How would you answer these questions and not have it be legal advise?

I'm quite certain the alteration is not only unethical but criminal. What about falsification though? Is that a crime as well? Is it a separate crime? Falsifying a medical record is illegal, legal fact. Little known fact, falsifying a medical record that is electronically transmitted is automatically a felony, legal fact. Note how I did not give legal advice in a formal manner as to how one would address this issue in a court of law.

I have copies of the MARs that she falsified and altered. Could this put me in violation of HIPPA laws?

And also I'm wondering if the same laws apply to all Nurses regardless of the setting? No, legal fact. Note that no legal advice was given as to handle this matter.

If it's against state law to alter charting entries, is this law going to apply regardless of the health care setting we work in or regardless of the employer?

Do the same laws apply to LPNs?

Not to be split hairs but I was under the impression that the TOS specified not to offer legal advice which is distinct from stating legal fact.

I know it seems like I am getting "legal" with these terms but they are very distinct terms that mean very distinct things. Legal advice is the formal act of giving an opinion on the meaning or substance of law as regulated by state and federal law. Giving legal advice is similar to the formal registered nursing assessment. Both formal acts are regulated by state and federal law.

Providing legal information is the act of reciting legal fact. To say that that the unwarranted killing of a human is illegal is not the formal act of giving legal advice but rather simply stating legal fact.

Splitting hairs I know but there really is a difference, look it up if you do not believe me.

[Jory, MSN, APRN, CNM]

Not to be split hairs but I was under the impression that the TOS specified not to offer legal advice which is distinct from stating legal fact.

I know it seems like I am getting "legal" with these terms but they are very distinct terms that mean very distinct things. Legal advice is the formal act of giving an opinion on the meaning or substance of law as regulated by state and federal law. Giving legal advice is similar to the formal registered nursing assessment. Both formal acts are regulated by state and federal law.

Providing legal information is the act of reciting legal fact. To say that that the unwarranted killing of a human is illegal is not the formal act of giving legal advice but rather simply stating legal fact.

Splitting hairs I know but there really is a difference, look it up if you do not believe me.

You are absolutely correct in your statement.

It is a good policy that AN has against giving legal advice but you are correct in stating that a legal fact is not the same as giving legal advice.

[Jory, MSN, APRN, CNM]

note: to be clear here I'm referring to the post from AKNorton on Sept 2 of this year,not resurrecting a thread where there is a two year gap with no messages.

I guess it would be common sense if we were discussing HIPAA and your facility's protocols for EMR and signing a document intended to absolve them of culpability should there be an illegal breach in the system. Thanks for the quick refresher course on documentation, though.

In this particular case we have one nurse who crossed out another nurse's entries on a paper MAR and supplied a different time and a manager who is unresponsive to the OP's concerns. Whether we're merely talking about a discussion rather than advice is hair-splitting and runs the risk of straying in that realm, which is against our Terms of Service here.

How would you answer these questions and not have it be legal advise?

I'm quite certain the alteration is not only unethical but criminal. What about falsification though? Is that a crime as well? Is it a separate crime?

I have copies of the MARs that she falsified and altered. Could this put me in violation of HIPPA laws?

And also I'm wondering if the same laws apply to all Nurses regardless of the setting?

If it's against state law to alter charting entries, is this law going to apply regardless of the health care setting we work in or regardless of the employer?

Do the same laws apply to LPNs?

I'm actually surprised you don't know the answers to these questions.

You do not have the right to cross out ANYONE else's documentation...you can ADD a documentation note and explain the correction, but you cannot cross out another nurse's note. Consult any NCLEX study guide as this well covered...it even goes to so far as to explain if it's your own documentation, that you cross out using ONE line (so the original can be read), state a brief one or two word reason for the change/ the date and your initials.

So no, that is not hair-splitting, that is pretty cut and dry.

As the other poster said...legal fact is not legal advice.

If you have copies of the MAR that were falsified and altered, then you need to be thoroughly educated on HIPAA. If you are a manager then it is your right to have access to all charts for review as part of a management team. HIPAA does not permit you to make personal copies of ANYONE's chart for personal use. Even THE PATIENT has to sign a document to receive information...so what makes you think someone would be entitled to it otherwise?

Anyone who is participating in an investitation (risk management, etc)...has the right to see the chart, per HIPAA.

Yes, the same laws apply to all nurses in all settings. HIPAA is very clear on that.

There is no "state law" against altering charts....that is why you never hear about nurses getting arrested for it, but they can lose their nursing licenses for it...it's against the Nurse Practice Act and an Ethical violation in every state.

Yes, the same applies to LPN's...they are nurses...why would you think they would not?

This isn't rocket science!!!!

[Susie2310]

xxxxx

[nursel56]

Not to be split hairs but I was under the impression that the TOS specified not to offer legal advice which is distinct from stating legal fact.

I know it seems like I am getting "legal" with these terms but they are very distinct terms that mean very distinct things. Legal advice is the formal act of giving an opinion on the meaning or substance of law as regulated by state and federal law. Giving legal advice is similar to the formal registered nursing assessment. Both formal acts are regulated by state and federal law.

Well that's weird, because just the other day I heard my cousin tell my uncle "you should sue that guy!" and I don't know how many times I've heard victims of domestic violence told by non-lawyers very informally to "take out a restraining order on that maniac", or perhaps something seemingly innocuous like "be sure and get malpractice insurance".

What is that called? Maybe the staff here will want to re-word the TOS as it is clearly aimed at non-lawyer users of a nursing forum and apparently understood for the most part, with the exceptions left up to the judgement of the non-lawyer staff and administrators here.

In any case I feel confident that the general readership here will not know "the facts" with respect to her dilemma at this time making this discussion rather a waste of time unless you enjoy semantic jousting as a form of recreation.

[nursel56]

I'm actually surprised you don't know the answers to these questions.

You do not have the right to cross out ANYONE else's documentation...you can ADD a documentation note and explain the correction, but you cannot cross out another nurse's note. Consult any NCLEX study guide as this well covered...it even goes to so far as to explain if it's your own documentation, that you cross out using ONE line (so the original can be read), state a brief one or two word reason for the change/ the date and your initials.

So no, that is not hair-splitting, that is pretty cut and dry.

As the other poster said...legal fact is not legal advice.

If you have copies of the MAR that were falsified and altered, then you need to be thoroughly educated on HIPAA. If you are a manager then it is your right to have access to all charts for review as part of a management team. HIPAA does not permit you to make personal copies of ANYONE's chart for personal use. Even THE PATIENT has to sign a document to receive information...so what makes you think someone would be entitled to it otherwise?

Anyone who is participating in an investitation (risk management, etc)...has the right to see the chart, per HIPAA.

Yes, the same laws apply to all nurses in all settings. HIPAA is very clear on that.

There is no "state law" against altering charts....that is why you never hear about nurses getting arrested for it, but they can lose their nursing licenses for it...it's against the Nurse Practice Act and an Ethical violation in every state.

Yes, the same applies to LPN's...they are nurses...why would you think they would not?

This isn't rocket science!!!!

I'm sure you are very knowledgeable. It shows in your writing. The questions I posted were from the other poster, not me, so whether I've ever heard of the one line through method of making a correction isn't the point nor was I confused about whether or not it would be OK to change someone else's entry into the MAR.

I'll stand by my advice to AKNorton and my opinion that whether you as a nurse know all the answers or not, you aren't a lawyer and the questions discuss what is and what isn't a crime, and as such constitute a violation of the legal advice rule of this forum.

[traumaRUs, MSN, APRN]

Now that we have strayed off course quite a bit in this 2+ year old thread, will close. Per our terms of service, we do not offer legal advice and/or medical advice.