is re charting legal - page 2
one of my unit managers often requests that we rechart...that is, that a whole page of hand written nursing notes is distroyed and we re chart the page to make it include something that was not in an... Read More
Sep 9, '06We just had a presentation at work by Risk Management on documentation, and this topic was covered. It is illegal unless you also include both sets of notes, the original and the revised; but in your case including both would defeat the purpose. Also, when an expert reviews the chart, it can be proven whether a whole page of notes was written at one sitting or over the course of the shift just by your handwriting. Your handwriting changes slightly when you are stressed, hurried, relaxed, etc. I know my handwriting is much better in the morning or when I'm having an easy day. It gets much messier when I'm rushed or dealing with a critical pt where things are happening very quickly. These are obvious differences, but experts know how to look for the slight differences in handwriting when there is a question of altering documents. I would not do it; this needs to be referred to your risk management.
Jun 27, '07I'm also in long term care and recently had a supervisor to tell me that charting on an "open area without bleeding or drainage" (I did not witness how it occurred) is incorrect.
I should have charted it as a laceration, though the incident, which turned out to be a cut, was not reported to me immediately.
Please comment with suggestions.
Jun 28, '07Quote from ZASHAGALKAIt's an illegal destruction and illegal alteration of a record. If a Court ever found out about this, it would completely destroy your credibility, not just in this case, but because legal cases are public records, in EVERY case you might ever be in thereafter.
(and that IS possible for defense attys to discover this due to the fact that sometimes such changes are enough to make that entry just not 'jibe' with the rest of the record, leading an atty to ponder to you in a deposition why that is the case. At that point, the illegal charting is either discovered, or you are forced to perjure yourself.)
And don't doubt that defense attys have experts looking over charts to discover EXACTLY this kind of illegal alteration.
You are so right, every deposition I have been to, the lawyers asked me "have you altered or changed this chart in any way or do you know of anyone else who has done so" You are setting yourself up for major problems. Does the DON know about this practise? Saying my boss made me do it will not help either.
Jul 2, '07I have used late entry many times when I realized I had left something vital out of my charting notes, but I would never destroy original notes once they are a part of the chart. Illegal to do so from my teaching.
Jul 2, '07Hello Right thing,
Chart exactly what you know, what you saw, what was reported and who reported the wound to you. Do not add or subtract important information. What we chart is the only legal record of our activities and patient status when there is an incident.
Jul 2, '07It's not legal here either.If we write in the wrong care plan sheet we put( ) round it and add "written in error" We used to have a Matron who had us re-writing drug prescription sheets whenever a drug was discontinued and scored through because she thought it was neater and signing them until it was pointed out to her that we are not the prescriber,the doctor is!