Re: Is it legal to alter RN documentation?
We are getting ready to go paperless. I think that they do enter a lot of the information via some computer program. You company is doing some slide of hand conning work though. You can always call Medicare if that is who is the primary payer and file a confidiental report.
I have seen that being in home health there is some dirtiness that I think is not ethical and sometimes questionable.
My only other thought is if she had some type of physical decline ie., falls, muscle weakness, balance issues---a PT could do an OASIS without nursing present if she refused PT. This would not sit well and the fact that they did not try and explain or retify the issue is a big red flag. I know you too must be frustrated that your work was destroyed too. I always get copies of every OASIS and note--invariably months later you will find in QA they lost a note and then you have to write/pretend? that you remember the vital signs. I keep my own schedule and check each pt off as well. They may an try and say you missed a visit and they need missed visit note etc., so stay organized. Good luck! It's a hard job, but I love my folks. They're the best...so that helps considering the paperwork can kill and burnout any good nurse.
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