I cutrently work as a telephonic call back nurse. I make follow up calls after pt's are discharged from the hospital. My boss is not a nurse, no medical title at all. Her mother was an RN and started the company, the gave it to my boss, I'll call her Angela. Anyway, once a call is complete she tends to edit them. She uses abbreviations that I do not example: changing "office" to ofc Lt (left) to "L" she tends to change the notes so they make sense to her. I feel that it is not acceptable for her to change my notes to her liking since I will be liable in the event something happens. Any suggestions are appreciated!
So long as she isn't changing the content of the notes, I don't see a problem other than it being annoying. Maybe ask her for a list of "approved" abbreviations that you can use.
If she is or begins to add/delete content then that's a whole different problem and I think, illegal.
Oh, HELL no. That is VERY much a problem. It is legal documentation of YOURS that she is changing.
Think about what would happen if you had to go to court. Your nursing notes are your legal foothold to show what you did and didn't do as a nurse.
There are also many abbreviations that are not allowed in nursing anymore due to the confusing nature of them.
If you had to go to court 5 years from now, and one of those notes were put into evidence, you'd be hung out to dry because 1) you wouldn't know what the heck they are saying due to her changing/adding abbreviations, and 2) the defense of "so and so changed my notes" wouldn't fly. Ultimately you are the nurse.
I would have this handled ASAP.
I'm thinking it's pretty illegal to change someone else's documentation... She can ask you to amend your own note but, she shouldn't be editing it herself. I'd probably try and speak to someone about this ASAP.
The boss is not changing the CONTENT of the documentation, only abbreviating where she sees fit. Like I said, certainly annoying but so long as she's not adding or deleting content then the documentation is intact as OP entered it.
Another thought, how is she able to access your notes? Do you make yourself a copy of your notes to make sure she isn't adding or deleting information?
Abbreviations matter just as much as full words in documentation.
Many institutions have lists of approved abbreviations, which I'd follow wherever venue they are generated in, because of consistency, and avoidance of commonly misinterpreted or illegible abbreviations, such as cc vs ml.
I wouldn't let anyone alter my nursing notes.
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