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Charting rules

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by nursejoe1271 nursejoe1271 (New) New

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My Don approached me and asked me to change my initial skin assessment from a month ago, the patient came in with a st II, she wants me to go back and change to an non-stagable wound. Is this fraud?

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TheCommuter has 14 years experience as a BSN, RN and specializes in Case mgmt., rehab, (CRRN), LTC & psych.

4 Followers; 226 Articles; 27,607 Posts; 321,263 Profile Views

If the patient was admitted one month ago with a stage 2 pressure ulcer, then yes, it would be fraudulent for you to alter your charting to indicate that the patient arrived one month ago with an unstageable wound.

If your DON wants the documentation altered, she needs to take accountability and do it herself. Do not get caught up in this! Fabricating documentation can result in your nursing license number being referred if anyone ever discovers this action. Integrity should be the name of our game in the nursing profession.

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3 Posts; 383 Profile Views

Yes thank you, that is what i told her, then she said, no you can add stuff, i told her that is still changing it, besides she did not have that when she came in. I only work therw prn, i do not know what has happened with the lady since then. I contacted the DADs agency

, i tried to call the BON but i never could get a person

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psu_213 has 6 years experience as a BSN, RN and specializes in Emergency, Telemetry, Transplant.

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Yes thank you, that is what i told her, then she said, no you can add stuff

And how does she think this going to look when the chart is audited by the state or whomever, and documentation was changed a month after the actual assessment?

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3 Posts; 383 Profile Views

And how does she think this going to look when the chart is audited by the state or whomever, and documentation was changed a month after the actual assessment?

Yea i dont kniw what she is thinking, shes only been the Don since may and shes allready trying to do this kind of stuff. She must think im some kinda fool to help her do medicare fraud.

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