All my documentation is missing....

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Specializes in Med/Surg/vascular surg/Rehab/LTC.

Hello all. For those who read my post about the stage 2 and the open area using skin prep here is my update.

Ive talked to ID and Nsg ed. The skin prep is incorrect....DUH....and now they are going to investigate the floor for using it on a open are......ok......that job is done thus far (if they actually do it) And they are already on a internal investigation about this RN manager for other skin issues......its been an ongoing issue and I was told that they were looking for proof that I might have found about her changing stage 2s to "moisture related".

Second.....ALLLLLL OF MY documentation minus my nurses note is MISSING. My skin sheets, diagrams and tracking sheets GONE. AND it was actually brought to the attention of a person that was there when i filled them out....and she was like HUH she did all of it and stapled it to office report.....WHICH I DID!! so now they are getting rid of documents.....great.....if they wanted to change the stage 2 to moisture they should have documented appropriatly on all of my sheets that they were doing so and then filed them with the old sheets.....but they distroyed everything related...and now they know that I know that they got rid of all of it....i made the other manager aware and also the ID nurse....and i will not back down on the fact that this action is INSANE and illegal!

Hope this makes sense....im rambling.... :)

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Make yourself a written document stating the facts to keep as a memorandum and put your guard up for the remainder of the time you are working in this unit. It is never a good sign when documentation starts to go missing.

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All I can say is WOW! Glad you're standing up for what's right! Also, do what caliotter3 wrote, it's a very smart idea. Keep us posted!

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Specializes in ER, Trauma.

Agree with Caliotter3, but go a step further. An anecdotal record is admissible in court. I'd go back and write down every detail I could remember, no matter how small. Reread your notes and add whatever memories they trigger. Then reread again in a day or two. You'll end up with solid protection for yourself, because nobody else Will protect you as well as you will. If asked, you might want to share copies, but protect the original, and anytime something triggers a memory detail, add it. In the future, make cross mentions of other forms in nursing notes, forms, etc, so you can prove they've been disappeared. CYOAF and good luck.

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Hmmm, time to start looking!! Sounds like some problems higher up. I'd be looking for another position asap. When things go "missing" it usually means trouble ahead. If someone is willing is destroy or get rid of documents, who knows what else they are capable of...

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Specializes in Med/Surg/vascular surg/Rehab/LTC.
Hmmm, time to start looking!! Sounds like some problems higher up. I'd be looking for another position asap. When things go "missing" it usually means trouble ahead. If someone is willing is destroy or get rid of documents, who knows what else they are capable of...

there are two good thing about this situation....IM AGENCY once my contract is up im outa here!!! Second thing is, per the ID and ED rns this RN manager is under internal investigations for this and other issues....so i dont think i have to worry here.....I want to speak with the DON on monday and If i receive resistance I will notify my agency and im out a here.....they have the contract they need to fill not me....as long as they fill it with someone its all good. I was asked by the DON to report any Abnormal findings and behavior.....and she asked me prior to her vacation if i would take a position here......HELL NO is my answer after this weeks goings on!!!

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Specializes in Hospital Education Coordinator.

you need to talk to risk management officer. This is against the law

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When in doubt, photocopy your work! Whenever there was an issue and I had to chart a long note or pull a diagram to fill out (due to something that someone else should have documented), I'd photocopy it and lock it up in the file cabinet! I know--sounds paranoid, but when paperwork ends up missing, it is impossible to find it.

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Specializes in Health Information Management.

I'd also suggest that you get the person who saw you fill everything out to write out a summary of what s/he recalls ASAP. Then make two copies, sign each copy in front of a notary and each of you will have a copy for your own (non-disappearing) records. It shouldn't be difficult to find a notary. Just call a couple of nearby bank branches; they almost always have a couple on staff. That's not intended as legal advice or anything like that; I just remember reading somewhere that in some instances having the document notarized can make a difference. Better safe than sorry!

Sorry to hear you're in such a fix. I agree that it sounds like it's time to look for a new job.

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first, i'm sorry but my brain is feeling a bit sluggish today, so if i missed something, i apologize.

is there a possibility that someone took your documents w/o notifying you?

maybe the DON, nm...afterall, there is an investigation going on.

there have been a few times that my notes and other documents had been missing, only to find out that someone took them without telling me.

yes, no, maybe?

leslie

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Specializes in Med/Surg/vascular surg/Rehab/LTC.
first, i'm sorry but my brain is feeling a bit sluggish today, so if i missed something, i apologize.

is there a possibility that someone took your documents w/o notifying you?

maybe the DON, nm...afterall, there is an investigation going on.

there have been a few times that my notes and other documents had been missing, only to find out that someone took them without telling me.

yes, no, maybe?

leslie

DON is on vacation that is why this thing is all screwed up. All other MNs are stating they never saw them and that my stapled reports never made it to morning report. I hope and pray they do showup, atleast I wont feel like my agency sent me to a facility that would compromise something like this. But as of now the ID, ED and all MNs have "no idea" where my three peices of documentation went!!! Atleast my note is still in the chart, although, I wish i could have the one paper that i stated it was pressure and moisture......im so irritated mty head is spinning....but whatever, i have only a month left to this assignment and 2 weeks of that are for my honeymoon.....and if it gets that bad, I will talk to my agency (which im going to call anyways and let them know the situation) and if it gets ugly, they can replace me......im ok with that.....there are 4 other assignments they want me for.....not a issue....

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Specializes in OB.

Since this could result in serious trouble you really need to contact your agency and let them know what is happening. Most agencies have a clinical liason, a risk manager and some sort of legal consultant.

Report to them now so they can assist you and so that if someone decides to turn the tables and dump the blame on you your agency will already know what is really going on.

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