Blatant false documentation

[Elpeon75]

Hi all!

A situation arose at work where documentation was changed two weeks after the fact to indicate a doc had assessed a pt in an emergent situation. The pt was never assessed by the doc. I then find out it was changed at the direction of the dept manager. I have gone to the dept managers boss and compliance. It's been 3 months and nothing has happened!? I feel like I need to resign and/or go further up the chain of command. Does it typically take that long for an investigation?

Thanks,

Elpeon

[Jory, MSN, APRN, CNM]

Hi all!

A situation arose at work where documentation was changed two weeks after the fact to indicate a doc had assessed a pt in an emergent situation. The pt was never assessed by the doc. I then find out it was changed at the direction of the dept manager. I have gone to the dept managers boss and compliance. It's been 3 months and nothing has happened!? I feel like I need to resign and/or go further up the chain of command. Does it typically take that long for an investigation?

Thanks,

Elpeon

I'm confused was it YOUR documentation that was changed? If that is the case you need to go up the ladder NOW and no, do not resign. You are legally responsible for what is documented under your name by you and if this was changed, you need to go to the highest level of management including your risk management officer.

Very, very illegal and if you resigned and something happened to that patient? The false documentation is the leg you'll be standing on.

[Elpeon75]

Was not my documentation that was changed. It was the docs documentation that was altered to indicate the pt had been assessed when in fact had not.

[NurseBlaq]

Was any harm brought to the patient? Was there a major change in status and that's why the chart was audited? I'm trying to understand if this is a major issue and harm was caused to the patient.

Not saying it's OK if not, just simply saying pick your battles wisely. If it's been months and nothing has been said or done either they won't address it or they have with the physician and you aren't privy to that due to confidentiality.

[serenitylove14]

I'm experiencing a similar dilemma, but it's the Np who i am replacing that is charting on patients he doesn't see. He has been charting on patients located at other facilities or that were previous patients in our system yet not located in any of our facilities. It wasn't me who found out but one of the other facilities I was training at that notified the NP that serviced that facility. So I did some digging, he has done it more than 4 times in the past month. Along with some other questionable behaviors like not addressing legit concerns that need medication treatment, I asked if I could cut my training short by a week. Honestly I don't want to be associated with this guy when **** hits the fan and he only has one more week until he officially leaves so I'm going to let him hang himself.

[kbrn2002, ADN, RN]

I guess from what I'm reading that this is not too uncommon. I work in a SNF, a former rounding MD's idea of rounding was to walk by the residents room and look in, make a note or two on the chart and move on to the next one. He rarely if ever actually laid hands on a resident or even talked to one. I guess he felt being in the building and noting in the charts was good enough. He retired awhile ago, while I can't say for certainty I doubt if anything was ever said to him about his rounding procedure before he left.