Another nurse is changing my documentation

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I am wondering if written shift report (is printed and placed in a binder and kept for x amount of time) is considered legal documentation? I (RN) work with another nurse who changed my shift report about an admission that I completed. Said nurse did not have any interaction with the patient but decided to delete some of the information that I had put on the shift to shift report without asking me or any consultation. I cannot find any information as to whether this is considered "actual documentation" because I have discussed this with other coworkers and apparently this is not the first incidence of this type of behavior. Any information or advice would be helpful! I am thinking of calling my state BON regarding this issue and do not care to start this procedure without getting some feedback from my peers. I am a charge nurse and this particular nurse is an LPN and we have had issues prior to this that have bordered on insubordination as well as general disregard for coworkers (e.g. leaving the floor without notifying anyone and not being able to be found for 40+ minutes)

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Specializes in Tele, ICU, Staff Development.

Your situation raises important concerns about professional conduct and documentation's legal status. Here's a breakdown of the key issues:

Legal Status of Shift Reports

Shift reports as documentation. While shift reports (sometimes referred to as "handover" or "change-of-shift reports") are not typically part of the official medical record, they can still be considered legal documentation within the context of nursing practice and could possibly be subpoenaed in court. These reports ensure continuity of care and accurate communication between shifts. If the report is written, printed, and retained, it could be considered a formal part of your documentation practices, especially if it is used for future reference or auditing purposes. 

Alteration of Documentation

 Changing any documentation without the original author's consent or knowledge, especially in a clinical setting, is a serious issue. Even if the shift report is not part of the official medical record, altering it is falsification, which breaches ethical and professional standards. This undermines patient care and trust among the team.

Professional Conduct

Insubordination and professionalism. The behavior you described, such as altering reports and leaving the floor without notifying anyone, points to a pattern of unprofessional conduct. As a charge nurse, you are responsible for addressing these issues if theyntake place on your shift.

Steps You Can Take

  • Document the incident. Keep a detailed record of the incident, including what was changed in the shift report, when it happened, and any discussions you had with the LPN or other staff members about it. In the future, take a picture of your documentation and let the LPN know you have photographed it.
  • Consult with management. Before contacting the state Board of Nursing (BON), discuss this issue with your nursing supervisor or manager. This is a performance issue with the LPN and should be addressed. 

Policy Review

Review facility policies. Check your facility's policies regarding documentation and shift reports. If there is no clear policy, this might be an opportunity to suggest creating one to prevent similar issues.

Conclusion

This situation is complex, involving legal and professional considerations. It is important to address it directly and professionally while ensuring you have the support of your management. You're right to take this seriously, as it impacts your professional integrity and patient care.

Best wishes,

Nurse Beth

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