Asked To Change My Nursing Note...

Nurses General Nursing Nursing Q/A

Hi guys, I just wanted a sounding board for this. I worked this weekend as a Supervisor, I'm an RN. We had a patient who needed Narcan, he had an order for it and we have a Narcan policy in the building. I went to the Med room to get it and it wasn't there, 911 was called and the patient ended up getting admitted to the hospital. I documented that the Narcan was not given because there was none in the building and MD Informed.  I documented that I informed the DON, who stated that she had the pharmacy remove the Narcan from the floor. I included that I sent the order to the pharmacy to be filled for house stock. I got a nasty email this morning saying to change my note to just say, "Narcan not given and unavailable". 

I think that's unacceptable, it's a doctors prescribed PRN medication that we were not able to give because it was removed from the floors and the DON had not communicated that with any of us (and I'm a supervisor). When a patient is missing a medication, I always charted the reason why it wasn't given and included the resolution- meaning order sent to pharmacy etc. I feel like I protected myself and my license, but I'm uncomfortable changing my note. Let me know what you guys think... thanks 

On 2/22/2021 at 8:11 PM, Sour Lemon said:

I think “narcan not available” along with your alternate action (calling 911) would have been more appropriate. It's really not your place to investigate and assign blame, much less chart the results of your investigation on the patient's medical record. Your additional details would have been better included in an internal incident report. 

Agreed! and since you are the supervisor and will be doing the investigation..a separate note for that is were all the other info about the narcan should be documented.

Well just a follow up, I changed my note the next day. I did write an incident report up and gave it to my DON, only to find it in the shredding box later that day. Very frustrating. 

Specializes in Psychiatry, Community, Nurse Manager, hospice.
7 hours ago, Cdonocdo said:

Well just a follow up, I changed my note the next day. I did write an incident report up and gave it to my DON, only to find it in the shredding box later that day. Very frustrating. 

Your incident report was shredded? By the DON?

Thats something I would take to the next level.

 

8 hours ago, Cdonocdo said:

Well just a follow up, I changed my note the next day. I did write an incident report up and gave it to my DON, only to find it in the shredding box later that day. Very frustrating. 

Ummm, I don’t think that’s kosher at all. Agree with FBT take this up the chain. It might get messy for you but it’s a patient safety issue. They might bluster about it but they are on the wrong side of the issue and the optics would be bad for them. Also, this might be a good time to dust off your resume. Your leadership is a mess and borderline corrupt. 

It is electronic nursing notes, nothing was hand written. 

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

Your original lives on, then. Really. You can't see it, and maybe other people can't see it, but if it comes to that, it lives in perpetuity in the server and can be retrieved c the right command by IT. And can be if subpoenaed. Your risk mgmt office knows this, so there's another person you can call p you start your new job. You ought to tell them about the missing naloxone anyway.

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.
5 minutes ago, amoLucia said:

It had always been my understanding that incidents reports were considered 'in-house' documents. And as such, it is up to each facility how to process the info presented. Once the incident has been reviewed, investigated and documented, and determinations made for remediation, the facility was free to dispose of in-house documents however it pleased.

Nothing I ever knew specified that there was some regulation requiring to maintaining incident reports for some spec length of time. Only that an investigation was mandatorily conducted.

Yep, you're right, a lot of people do believe that.

I have seen plenty of "incident reports" and "variance reports" that showed up in discovery, though.

On 2/25/2021 at 7:32 PM, Cdonocdo said:

Well just a follow up, I changed my note the next day. I did write an incident report up and gave it to my DON, only to find it in the shredding box later that day. Very frustrating. 

Ouch. I assume that you were meant to see that, too. Is there a bucket of paint laying around somewhere that you could throw on her car?

Specializes in NICU.

Oh my goodness,change/correct that entry,it is very unprofessional,you look like you did nothing for patient except chart a bunch of new grad notes. We had some doctors chart stuff like about "incident report"made out.Ugh.

I wouldn't change my note,  but I also wouldn't have written a note like that in the first place.

The chart should objectively state information about the patient's health and care given.  The chart is not the place to describe workplace conditions,  relocated medications, etc. It is a legal document telling the patient's story- not the story of your experience. 

Specializes in Critical Care.
Cdonocdo said:

Hi guys, I just wanted a sounding board for this. I worked this weekend as a Supervisor, I'm an RN. We had a patient who needed Narcan, he had an order for it and we have a Narcan policy in the building. I went to the Med room to get it and it wasn't there, 911 was called and the patient ended up getting admitted to the hospital. I documented that the Narcan was not given because there was none in the building and MD Informed.  I documented that I informed the DON, who stated that she had the pharmacy remove the Narcan from the floor. I included that I sent the order to the pharmacy to be filled for house stock. I got a nasty email this morning saying to change my note to just say, "Narcan not given and unavailable".

Don't do it!  This reminds me of the ongoing lawsuit of a cancer patient Kim Johnson who was sent a letter claiming her mammogram was normal in error.  Months passed before she received a second opinion and then was found to have stage 4 cancer!  A forensic audit of her medical records found they had been altered after the lawsuit to cover up this error.  Please see this article https://www.nbcnews.com/news/us-news/kentucky-mom-alleges-hospital-workers-missed-her-cancer-then-covered-n1258533

Don't let them pressure you into changing your documentation.  It is both unethical and illegal.

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