is this legal?

I am a lowly CNA who *just* got into the RN program on rolling admissions for next Spring, so please know that this is mostly intuition I am going by. This is absoletly against the very little I learned about charting in my CNA course. I learned that there was a procedure for correcting errors in charts and NEVER actually remove any documents or notes. The pt has a legal right to see their medical records and to me it is obvious that removing things from the medical record is not legal. The hospital is covering their butt and trying to avoid blame in a lawsuit. POSSIBLY, they are keeping the notes and accident reports for safekeeping elsewhere to make sure they don't get lost. That is about the only positive reason I could think of for removing them.

WOW, Im glad that the facility is being under investigation. It sounds like someone is trying to prevent the facility from shutting down.

Sounds like a cover-up.

You cannot edit someone's charting. You cannot remove part of the chart. Incidents MUST be charted or it is considered conspiracy to conceal.

If someone is editing your charting or removing it you are obligated to report it immediately. To fail to do so makes you legally liable and a party to the conspiracy.

Contact your BON immediately.


BTW make sure to get insurance, if I was a lawyer everyone and their mother would suddenly become poor.

Simply put, not legal.

Nope.

your instincts are correct...they may NOT remove or edit your nursing notes. It is time for you to practice some sincere CYA cuz there is going to be some trouble in your place of employment.

Absolutely not.

Are you very sure that what you think happened is what actually happened? After a serious fall, administration will often review charts and take and copy documentation related to the incident. Did you check the chart at any time after you noticed your note was missing? It might have been put back.

By the way, did you happen to mention in your note that you'd done an incident report?

If you saw the DON and managers taking charts for review after a fall resulting in fatality, don't be surprised. That was a reportable incident and the facility was required to self-report the event. Further, every facility I've worked in has responded to the possibility of ensuing investigation the same way: chart audits.

Finally, I've learned over the years that if one coworker tells you something uncomplimentary about your employer, take it with a grain of salt. Your DON is not required to report every fall to the state, and it would be unfeasible to edit each and every chart note regarding falls. It would also be terribly obvious if the notes were edited.