Altered and removed charting

  1. I came to work and while making rounds, a pt, 75, who was 5 days post-op from a pacer install told me that 24 hours earlier that he had been given a wrong med, Ditropan XL 5mg p.o., which was another residents RX. He also told me about how the aide tried to talk him into letting her stick her finger down his mouth to induce vomiting!

    I had heard about this, so i knew that it had happened. When I checked, there was nothing charted...nothing! I charted..by hand, what the pt told me and that I could not find any documentation anywhere, so i referred it to the RN in charge on a.m.'s. She left me a voice mail saying that I should not have written any of what I was told. When I came to work last night, the RN had torn my charting out completely and re-created the top of tyhe chart, with two entries by other staff, forging their writing and signatures. Trouble is...I had made copies of my charting and when you compare them, it is obvious what she has done.

    Sooo, what would you all do??

    Thanks!
    Greg
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  2. 24 Comments

  3. by   Ahhphoey

    Wow, the lengths that some go through to CYA. I would go over her head to the unit manager or ADON, which ever is the next notch at your facility. That is just horrible and the nurse that destroyed and then rewrote those notes needs to be disciplined. I hope everything works out.
  4. by   marcyga
    How scary how much of your other charting gets thrown away? First of all only chart facts about your patients condition, don't cut your peers in patient charts. Take your copied documentation, and the present chart to the next higher up from your charge nurse and let administration handle the problem.
  5. by   jemb
    Makes you wonder how many times this has happened and you never heard about it, doesn't it?

    This is the sort of thing that the BON would take disciplinary action for.
  6. by   Marie_LPN, RN
    Saw this happen once before, soon as the inquiring nurse went to the nurse manager about the chart-altering nurse, she immediately called human resouces and the alterer was fired on the spot. Why? She'd had fudge 3 sets of Q4 vitals on her 5 patients, stating she "didn't have the time to get them". How did they find this out? Three of these patients were keeping track of their vitals on paper so that their family would know how things were going without asking the nurse to look it up, and they had 3 blank spots, and asked the relief nurse what was going on, since no one had done vitals "for awhile". Asked the other patients, one said they hadn't either, the other one has dementia and could not remember.

    Now what if someone had a high fever? Or tachycardia. Or outrageous low or high BP? No one would have KNOWN!!!
  7. by   redshiloh
    Oh yeah, it happens. I remember an RN in LTC 'prerecording' all her VS...I always wondered what they would do if someone died and VS on them. And yes, the DON and owner of the facility knew.
  8. by   Marie_LPN, RN
    Makes them just as guilty

    What a shame
  9. by   sanakruz
    Did anyone let the MD know his/her pt received the wrong med????
    Go right to the BON, forget management, and find yourself an better position. This is extremely dysfunctional, xtreme!

    Never mind the felony of destroying/changing a medical record, someone could be killed! Med errors happen- This wasnt a big deal in the scope of errors, so why is everyone trying to go underground???? Not good
  10. by   Xtreme1
    I went to Admin this a.m., haven't been to sleep yet! I also contacted the BON and one of their investigators, we'll see where it goes from here. Now, I fear some type of retribution once she finds out! I REALLY appreciate all of your insights! Thanks a lot!

    Greg
  11. by   canoehead
    Excellent job. I would think about moving to another position if your administration does not come down hard and fast on that charge nurse. Expect her to be fired, and if not get out of there.
  12. by   AndyLyn
    At our hospital, we've been instructed not to chart about med errors or falls, etc. on the patient's chart, but instead to fill out an incident report and not to refer to the incident report anywhere in our charting. I agree that the charting you did should not have been altered by anyone else, but I can understand why you couldn't find it in the previous charting.
  13. by   Noney
    I don't even want to touch this one!
  14. by   jemb
    Originally posted by AndyLyn
    At our hospital, we've been instructed not to chart about med errors or falls, etc. on the patient's chart, but instead to fill out an incident report and not to refer to the incident report anywhere in our charting. I agree that the charting you did should not have been altered by anyone else, but I can understand why you couldn't find it in the previous charting.

    It is true that putting anything about writing an incident report in the patient's chart is a red flag for anyone who decides to file a lawsuit.

    However, how can you chart your follow up to the problem if you do not mention that it occurred (without calling it an incident, of course) in your charting. You need to chart what you did to resolve the problem, i.e., "Dr. X informed that Mr. Y found by RN on the floor in bathroom. No visible injuries noted. X-ray of RUE ordered due to pt c/o pain at elbow.." etc.

    In the case of a patient saying the wrong med was received. charting could be something like, "Informed Dr. X that Mrs. Y believes she received an unfamiliar medication this morning. States she received a red pill in addition to several that she recognized". Then document whatever you did in response to any orders you may have received.

    Be objective, avoid any finger-pointing, and take care of business.
    Last edit by jemb on Jul 31, '03

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