Changing time on nurses note

[dlarena]

I noticed that the time of documentation was changed on two of my nurses notes. The same person documented under my note each time. I report this to my Manager who took it to H.R. When the person was confronted by H.R. they denied doing it. H.R. said that she denied doing it and they have no proof so there is nothing they can do. This person has not spoken to since this happened. Is there something else I can do about this or do I just let it go? I'm still upset about the whole issue. Any thoughts or comments?

[cowboy up]

First of all,when you are finishing a nurses note no matter how much space is available on the page CROSS OUT THE REST OF THE PAGE!!!Then you initial under the time of your entry so there is no doubt about the time. As for the nurse that altered a legal document ALTERED A LEGAL DOCUMENT, the further you can get from him/her the better because that nurse is going to go down in flames eventually. It's disgusting that a nurse like that still has their license.The name of the game is cover your own butt.You did the right thing in reporting it and don't for a second think you did anything wrong.

[jadelpn, LPN, EMT-B]

-----------dlarena, RN 10/16/14 0700----------------every entry, every time.

I do not know why this is happening, I would contact your malpractice insurance and advise them just to make them aware. You do not want to be held responsible for someone else's illegal activity. I would not have a clue why someone would do this, other than to make you look like you are not doing your job correctly? Or that her timing then becomes correct? And you can't change/cross out without an "error" and your initials. Is this what is happening?

And no bother that this person is not speaking to you anymore. Good. Perhaps now she will not longer alter your documentation either.

I would ask that you are able to re-correct the time if it can be poorly reflected on your practice to keep the altered time on there. And do call your malpractice insurance. There's something weird going on, and I would be sure that you cover yourself 100%.

As a complete aside, if this is EMR charting, it would be really, really easy for them to figure out who did what when, as it leaves a footprint of same. But I am assuming this is paper charting. Don't leave a bit of room for someone to alter anything.

Oh, and be sure to write down and keep when you noticed, when you notified, and any corrective action that they asked you to take, if they did. Protect yourself. And if the other nurse denied it, are you sure that it was this nurse? By the handwriting, how can you be sure it was? I only throw that in there because at the end of the day it is an illegal alteration of a record, but remember it could be any one of your co-workers. So cover yourself, always.

[caliotter3]

When a coworker had concerns with their charting being altered after the fact, they engaged the use of a different kind of pen that used a different kind of ink, like a sharpie marker instead of typical ink. Perhaps get two other types of pen and mix them up when using them, as long as the ink color (I assume black) stays the same, nothing can really be said. Writing like this will make it more difficult for the other person to mess around with your charting.

[firstinfamily, RN]

I agree with all the above and am also assuming this is paper charting. If there was space after my documentation I would draw a straight line across or use X's to cross out that blank space; that way no one could document in that area. The entries should always be dated and timed, you could also circle the time so that it will not be easy to write over etc. EMR would leave a footprint as to who was documenting at what time.