Deleting nurses notes

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I work in a facility that uses computer nurses notes. Recently, a few of the nurses that work here, including myself, had our nurses noted deleted from the computer because the management stated our notes told too much of the truth regarding a behavior on one of our residents. All of the info contained in our noted was accurate, the truth, and totally described this residents behaviors to a "T". How legal is it to delete out notes from a residents personal chart? Anyone have any thoughts or opinions? Has this ever happened to anyone else?THANKS

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Specializes in Peds Homecare.

Nurses note are a legal document about what happened on your shift. I have no idea why they deleted them. I really feel this is not legal for them to do. Also, did they doctor them and sign your name? That is totally illegal. I'd go up my chain of command, it was totally wrong. If it was me I'd fight it, and if they threatened you, tell on them to the BON. They had no right to do that.

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Specializes in NICU, PICU, PACU.

There is always an audit trail, even if you delete something, it really isn't totally gone from the electronic chart.

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I've worked in facilities where notes were removed from the chart, or altered, back when we were using hand written notes. If it were me, I would seriously consider starting a job search. I would not want to continue to work where I was being placed in legal jeopardy by my employer.

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I'm not sure what program you use at your facility but at my job you can always delete but it'll still "show up" It'll just have a red line going through it and to the side in parenthesis it'll say "deleted" but you can still open and read it. However, you can always modify but there must be a reason as to while you're deleting or modifying entered into the system as well. And it'll always say WHO modified. That's the important part.

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Specializes in PCU.

I was always told notes made on a patient's chart are legal documentation and it is illegal to delete them as your management is doing...I would consider finding another job where they do not engage in questionable practices.:twocents:

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Specializes in LTC, Nursing Management, WCC.

1. As OP stated, there is always an audit trail

2. As another poster stated, it more than likely will have the person's sign on or initials as the person who "deleted" them

3. You might be able to pull them up if you have the options to look at discontinued or deleted entries

4. Look for a different job. The only person who should be adjusting their charting is the original author.

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Agree with previous posters, this isn't right and with electronic documentation nothing can ever be completely deleted.

You say the notes were accurate, but you were told they 'told too much of the truth'. I take that to mean that the notes somehow made management look bad. Is that how it was?

The only thing I'd ask is was there anything in the notes regarding what was done about the behaviour, what approaches were tried, who was notified, etc, etc. The notes are not the place to start a war against management, no matter how ineffectual, useless, or blind (deliberately or not) to what is going on they are.

Not saying this is what happened, only that I have seen this, and it isn't right either.

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Specializes in LTAC, ICU, ER, Informatics.

Speaking from the computer angle, the system should not allow deletions. Whether it's indicated as other posters have stated as still being present with strikethrough or just present on audit, that data should not be able to disappear. I cannot conceive (as a programmer) of a medical records program that would allow it since it's highly regulated. Statutory requirements are VERY prominent and adhered to (not to mention thoroughly tested) during development.

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Specializes in CriticalCare.
Nurses note are a legal document about what happened on your shift. I have no idea why they deleted them. I really feel this is not legal for them to do. Also, did they doctor them and sign your name? That is totally illegal. I'd go up my chain of command, it was totally wrong. If it was me I'd fight it, and if they threatened you, tell on them to the BON. They had no right to do that.

yep, not legal from the BON pov. I am not sure if it is criminally illegal unless medicare/medicaid was involved.

if a nurse was involved, getting the state BON involved is one course of action.

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Specializes in CriticalCare.
There is always an audit trail, even if you delete something, it really isn't totally gone from the electronic chart.

wrong.

they can go to the IT department and have the files electronically shredded wherein there is no chance of recovery whatsoever.

i am security+ certified and know this to be a fact. The computer admin has the ability to remove all traces of any documentation and file--they have the programming and network experience to remove information from proprietary systems, writing random zeros and ones over the sectors where the data resided.

the CEO of the hospital along with the attorney could ensure this course of action

now, if a NURSE or standard user account tried to delete the data, yes, most competent IT departments have the 'unaldulterated' data--but as i said, it CAN be permanently deleted with no chance of recovery.

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Specializes in CriticalCare.
Speaking from the computer angle, the system should not allow deletions. Whether it's indicated as other posters have stated as still being present with strikethrough or just present on audit, that data should not be able to disappear. I cannot conceive (as a programmer) of a medical records program that would allow it since it's highly regulated. Statutory requirements are VERY prominent and adhered to (not to mention thoroughly tested) during development.

you may be a techie, but i am here to tell you that any proprietary system wherein the user has admin priviledges to the filesystem has the ability to be decompiled (.net is easily decompiled with salamander.net and others)

I am not going to get into the details, but everything electronic boils down to zeros and ones at one point, whether it be in memory or on a disk. There are several tools in a crackers orificenal (many use the term 'hacker' incorrectly) that allow such things to be accomplished.

It may take some time, but even proprietary, encrypted systems wherein an admin did not have access to directly can be 'de-crypted' and accessed without a trace (but it may take some time).

However, it is unlikely that the software would have such a feature anyway as they expect the super user/admin to never do such an activity--the govt. implements systems like this, but a commercial app for a hospital?

not likely

i am done with the subject matter. if u disagree, you simply are mistaken. it may not be straightforward, but with the correct set of tools and free access to the filesystem, it most definitely can be done, even with a system that doesnt allowed it under any circumstances. simply loading the record itself brings the data into memory/ram where it can freely be deleted by said tools (there are no file restrictions, ie read only)

but a better way, imo, is to crack the app itself so you have complete control, rather than playing around with other methods.

and heck, the guy is getting paid to do it to.

cracking the encryption, however, wouldnt be 'legal', but it is done every day.

i worked with russian programmers from 1998 to 2009--the things they were capable of were amazing.

and the chinese have government backup, so their resources are unlimited.

I dont know what tools and resources these particular admins have in their It dept. but saying it CANT be done demonstrates a lack of understanding of the underpinnings of electronic files, programs, filesystems, and OS's

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