should this also be included in handover

[efRN]

I was told by Nurse A during handover that they have to erase Nurse B's nursing notes in the chart as the the incident was not supposed to be written in the progress note.(I know that you are not allowed to just erase somebody's charting, I asked her why but she said that it was per manager's order). The incident was we had a patient going to a high level facility(mental health needs) and the family felt that the patient was roughly handled by carers, what happened was written by Nurse B in the chart. The next day the family came and talked with the manager, then that same day they erased Nurse B's notes in the chart. I don't know how did they ever come up with that decision and if they know that it is illegal to just erase somebody's notes. I felt that I should also tell this on the next shifts handover, as the nurses in that facility I think that everybody in the team has to know what has been happening and it was also part of patient care we have to know. Then this reached to Nurse B. They've already talked with the manager regarding this. Did you think I did the right thing of handing it over to my other collegue about what happened?

[Rob72, ASN, RN]

It is illegal. I would not touch it with a 10 foot pole. I would not be talking about this. Period.

While its nice to say, "we should all know...", the truth is,

a) there was a discussion with the Legal Dept (to which you were not a party) and it was decided to strike the note, and place a Note To File, indicating that the information was inadvertantly recorded in an inappropriate location, and has been replaced appropriately,

or b) medical records have been deleted/altered without annotation (illegal), and by stating your awareness, you are assuming legal responsibility (under Duty to Report).

[efRN]

I was not the one who erase the notes, i was informed during handover by Nurse A of what the manager did and when Nurse B known about this he was furious because the manager did not discussed it with her, she was the first one to make a move and tried to ask the manager on why they erased her notes.

[Rob72, ASN, RN]

No, I understood you. My point was that, yes, it is illegal, and that by acknowledging your awareness of the act, you have assumed liability under Duty to Report, particilarly if your facility receives Medicare/Medicaide money.

To be blunt: if you don't talk about it, no one can prove that you were aware of the act.

Just be careful. Having been in a similar situation, if you don't have a way to get the manager fired, I'd be job hunting.