Deleting nurses notes
- 1Nov 23, '11 by Rugford5LPNI 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 truth regarding a behavior on one of our residents. All of the info contained in our noted was accurate, the truth, and totally described this residents behaviors to a "T". How legal is it to delete out notes from a residents personal chart? Anyone have any thoughts or opinions? Has this ever happened to anyone else?THANKS
- 6Nov 23, '11 by realnursealso/LPNNurses note are a legal document about what happened on your shift. I have no idea why they deleted them. I really feel this is not legal for them to do. Also, did they doctor them and sign your name? That is totally illegal. I'd go up my chain of command, it was totally wrong. If it was me I'd fight it, and if they threatened you, tell on them to the BON. They had no right to do that.
- 6Nov 23, '11 by caliotter3I've worked in facilities where notes were removed from the chart, or altered, back when we were using hand written notes. If it were me, I would seriously consider starting a job search. I would not want to continue to work where I was being placed in legal jeopardy by my employer.
- 0Nov 23, '11 by DazglueI'm not sure what program you use at your facility but at my job you can always delete but it'll still "show up" It'll just have a red line going through it and to the side in parenthesis it'll say "deleted" but you can still open and read it. However, you can always modify but there must be a reason as to while you're deleting or modifying entered into the system as well. And it'll always say WHO modified. That's the important part.
- 4Nov 23, '11 by PsychNurseWannaBe, BSN, RN1. As OP stated, there is always an audit trail
2. As another poster stated, it more than likely will have the person's sign on or initials as the person who "deleted" them
3. You might be able to pull them up if you have the options to look at discontinued or deleted entries
4. Look for a different job. The only person who should be adjusting their charting is the original author.
- 1Nov 23, '11 by CompleteUnknownAgree with previous posters, this isn't right and with electronic documentation nothing can ever be completely deleted.
You say the notes were accurate, but you were told they 'told too much of the truth'. I take that to mean that the notes somehow made management look bad. Is that how it was?
The only thing I'd ask is was there anything in the notes regarding what was done about the behaviour, what approaches were tried, who was notified, etc, etc. The notes are not the place to start a war against management, no matter how ineffectual, useless, or blind (deliberately or not) to what is going on they are.
Not saying this is what happened, only that I have seen this, and it isn't right either.
- 2Nov 24, '11 by theantichick, BSN, RNSpeaking from the computer angle, the system should not allow deletions. Whether it's indicated as other posters have stated as still being present with strikethrough or just present on audit, that data should not be able to disappear. I cannot conceive (as a programmer) of a medical records program that would allow it since it's highly regulated. Statutory requirements are VERY prominent and adhered to (not to mention thoroughly tested) during development.
- 1Nov 24, '11 by zcoq72mehsQuote from realnursealso/LPNyep, not legal from the BON pov. I am not sure if it is criminally illegal unless medicare/medicaid was involved.Nurses note are a legal document about what happened on your shift. I have no idea why they deleted them. I really feel this is not legal for them to do. Also, did they doctor them and sign your name? That is totally illegal. I'd go up my chain of command, it was totally wrong. If it was me I'd fight it, and if they threatened you, tell on them to the BON. They had no right to do that.
if a nurse was involved, getting the state BON involved is one course of action.