Deleting nurses notes - page 4
by Rugford5LPN | 5,440 Views | 33 Comments
I work in a facility that uses computer nurses notes. Recently, a few of the nurses that work here, including myself, had our nurses noted deleted from the computer because the management stated our notes told too much of the... Read More
- 0Nov 30, '11 by unrealThis is so infuriating! I left a LTC facility 3 mos ago because I could no longer stand their toxic/unprofessional/disorganized/insubordinate/sleezy ways!!! I don't recall having my charting altered, but there were times when I would document things like bruises (BIG BRUISES) big enough to require being reported to the state only to have the DON have another nurse follow up on it and state that it was not a bruise at all. Ridiculous!!!!! I was an excellent nurse for that facility and always recieved excellent evals. I gave notice per policy and then left. I did not have another job lined up. I am now looking for work and the DON is now being passive/aggressive about giving a work reference for me...takes her 3 WEEKS to respond!
I know this is off topic...sorry for the vent.
- 0Nov 30, '11 by VinniesguyAltering someone else's notes is totally against the law. If there is a coroners case and your notes don't match what you're saying you're in big trouble. However - another people have said, if someone else alters your entry there will be a 'last modified by' and the date it was modified in the file information notes
- 0Nov 30, '11 by PsychNurseWannaBe, BSN, RNOK...this is under SNF, I am thinking the typical SNF. I don't think you have to worry about someone hacking the system to delete the note without leaving a trace. But thanks for bringing the topic about what IT can do. I found it very informative. I kinda knew they could do things because I worked for an insurance company and everything was on computer and sometimes things just "disappeared".
- 0Dec 2, '11 by Lynx25I'm so glad I am not the only one with this problem!
I had a lady who developed two large pressure sores to the back of both heels- and dutifully put them in the system.
Two days later, the 'wound nurse' had come in, deleted BOTH of my entries, and put in the system that this (non-ambulatory) woman had aquired abrasions to her heels, from (fictional) shoes, that the (never, ever, ever present) family had brought in.
I was furious, and pitched a fit for about two weeks. No one ever bothered about it, so eventually I gave it up.