Altering documentation?

pickledpepperRN · Mar 3, 2007

I once documented that a physician did an admission physical on a patient at 2:00 am. He wrote in the margin of the nurses notes, "Was this necessary?" with an arrow pointing to my entry.

He had written 9:00 pm on his progress notes.

He goes home to be with his family after closing the office and then comes to the hospital. At that time he gave admitting orders by phone. Now they can do it by computer based on a conversation with the ER MD.

He said it looked like he woke up the patient. We said, "You did wake her up."

We all wrote an incident report because it was 2:00 am. He is actually a good doctor, always listens to nurses, and saves lives in our ICU.

suzanne4, RN · Mar 3, 2007

I have had a resident write orders and time them for two hours before with me standing in front of them. And several times it was for an order to extubate the patient, but funny blood gases were not done until way after that time.

Copies were made and sent to their chief. Never happened again.

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Once that order was noted and signed off, they cannot add one thing to it.

And sorry, they know that they can't. Just make sure that you made a copy of it and submitted it to your manager and even risk manager, of need be.

Best thing to do is place a line under where the orders were signed off at, then nothing can be added.

Jolie, BSN · Mar 3, 2007

I once cared for a preemie almost ready for DC who suddenly and unexpectedly developed a feeding intolerance. This began the day that her feeding orders were changed by the neonatologist. He had miscalcualted the concentration of her formula (mixed from powder), and she was being given formula that was more than double strength. One of our nurses found the error in the doctor's orders and pointed it out to him. She then contacted pharmacy (where the formula was mixed). Apparently the doc beat her to it. He went down to pharmacy and retreived the written copy of his order, replacing it with a newly written one. He was able to do this since the order happened to be written at the top of a new page with nothing else written yet below it. He destroyed the original in the chart and claimed innocence.

As the manager of the unit, I made it clear to him that while I couldn't prove his misdeeds, I knew what he had done, and so did other nurses on the unit. It was really too bad, because he lost the trust of everyone who knew of the incident, and other than his obvious lack of character, he was a really good clinician.

SmilingBluEyes · Mar 3, 2007

I would complete an incident report on this, not only to CYA but to alert those who need to know, what this person is doing.

RunningWithScissors · Mar 4, 2007

Our charge nurse checks all the blood transfusion records and changes the times on the vital signs if they aren't "on time" to make the documentation look better.

SmilingBluEyes · Mar 4, 2007

Illegal!!!!!

PANurseRN1 · Mar 4, 2007

Not only was altering the orders inappropriate, it was way out of bounds for that resident to have confronted the OP. You can bet I would have written that up, too. That's harrassment.

Agnus · Mar 4, 2007

As a legal nurse consultant

Altering documentation is a bigger liability than leaving documentation that is self incriminating. Once alteration in documentation is detected by someone working for an attorney or the attorney hisself. (and it easily is) there is no question that the hospital and the doctors and nurses will loose the case. Even those who did not actually do the alteration. May seem unfair but that is how it works.

EmerNurse, BSN, RN · Mar 4, 2007

Whenever I sign off orders, I draw the line and put my signature JUST close enough to the orders that it's impossible for anyone to add anything.

My ER pet peeve? Doc write order without a time (they're not supposed to) - I complete order and write time completed next to it. They go back later and add the time to it (the time they SAW the patient, not wrote the order) thereby making it look like the nurse didn't complete the order in the required timeframe. ARGH. Now, if there's no time, I make them write it. And if they sat on that chart, I make them time it for when I was given the chart, NOT the moment they sat down to document (an hour earlier).

Bah - sometimes you can't win for losing.

TazziRN, RN · Mar 5, 2007

They go back later and add the time to it (the time they SAW the patient, not wrote the order) thereby making it look like the nurse didn't complete the order in the required timeframe.

Why in the world would the docs want to make the nurses look bad???

I once had a doc accidentally order an abx twice on the same pt, several hours apart. The order sheet was pretty full and I didn't notice that it had already been ordered and given on days. I found it after the pt was discharged. I brought it to the doc's attention and told him I had written an incident report already, and he changed things to make it look like the order was deliberate, that the pt needed the meds of mass destruction. He accused me to trying to make him look bad!

Tiwi · Mar 5, 2007

Working night shift the other night I came across orders for patient to be discharged to NH the next day. They had not been signed off, so I did so with a time of 0005, started the discharge paperwork, then completed 24 hour chart review and signed that at 0030.
The next morning the resident made rounds (2nd year I think - been around long enough to know better ) and wrote orders above my signature, added something to the discharge orders, crossed off another order, and changed my discharge paperwork. When I came across the orders before I left that morning, I called him and told him he could not alter a document after it had been signed off by a nurse, and he acted like it was no big deal. I then wrote an incident report as instructed by the nursing supervisor. The next morning, he confronted me about it and said that he didn't mean to do anything wrong, blah blah:rolleyes: , and that he was told he could be charged with fraud. I explained that he should have known that and had I not written it up it would have fallen on me as the responsible party (and you know, we nurses do not take the fall for a doctor!). (Yes, I have copies of everything!)

Good for you. I hope he wasn't nasty about it. It is illegal; and as you say, nurses are easier targets than doctors. Besides, he should have the same knowledge, if not more so legally. The fact that he was warned he could be charged with fraud indicates how seriously it was taken...

I have had a couple of incidents where this has happened. There were no legal issues that eventuated, but the use of an incident form in the future is a great idea. Thanks!