Deleting nurses notes

As NicuGal mentioned, there is always an audit trail.

My facility utilizes an EMR and we are allowed to modify or unchart things, but it is still visible in the chart and anyone who has access to the chart can see that.

this simply is not true if the adminstrator user has access to the filesystem without restrictions.

as a nurse, yes

but not as an employee in the IT dept. where these servers are sitting

it is not my fault ppl do not understand the technical details of how systems are thwarted.

is it common in the nursing industry? no

can the data be adulterated and deleted without detection: absolutely

anybody who thinks otherwise simply lacks the proper knowledge, and i dont expect nurses to know-how

be well

Totally unethical to alter someone else's notes. Tell them to reinstate your notes before you report them to the BON. Contact the BON anyway.

Start looking for new employment immediately.

Be certain that your notes are as objective as possible. No opinions, no theories.

Best wishes.

altering medical records is a crime.

regardless of the forensic recovery potential and ability (which is really legally moot here), destroying or changing medical records, especially if any sort of payment (insurance) or quality of professional practice oversight system is involved, is generally considered a criminal act.

further, if medicaid or medicare dollars are indeed involved here, participants or those with knowledge that bring this to light may also be considered protected witnesses under federal whistle blower laws.

additionally, while state boards of nursing would likely look dimly on this, they have nothing to do with it as the practice of nursing professionals are not in question. rather, it was an administrative decision to delete those professional records. hence this is purely an issue of institutional directed or orchestrated fraud.

either way, as others have alluded to, i suggest those who are involved contact their attorneys. good luck, but this sounds like the type of mess and the type of work environment, that i wouldn't want anything to do with.

Do you have a compliance hotline?

Wrong on so many levels, as previously mentioned, there should still be a record of it even if they deleted it. If you don't want to start a job search, I would ask for a meeting and politely ask them to approach you when they feel the nurses notes need to be amended so that you can figure out together how to write what you want in a way that is acceptable by them. I would also ask them to at least inform you when they are altering notes. In our facility we have to print the report daily (yes we know that forests are being sacrificed for this and we are against it but our DNS insists, We think it is because she is so uncomputer-savy she prefers to read the paper version than sit in front of a screen) so even if they delete, our version is printed.

I do not think it is ethical what they did, and have to wonder why they are doing it. What benefit do they gain? Is a patients reputation at stake? Will your report change funding? Is the nurses note an invitation for a lawsuit?

I dont think they would take the time to do it if there wasnt a reason. Any ideas?

This is so infuriating! I left a LTC facility 3 mos ago because I could no longer stand their toxic/unprofessional/disorganized/insubordinate/sleezy ways!!! I don't recall having my charting altered, but there were times when I would document things like bruises (BIG BRUISES) big enough to require being reported to the state only to have the DON have another nurse follow up on it and state that it was not a bruise at all. Ridiculous!!!!! I was an excellent nurse for that facility and always recieved excellent evals. I gave notice per policy and then left. I did not have another job lined up. I am now looking for work and the DON is now being passive/aggressive about giving a work reference for me...takes her 3 WEEKS to respond!

I know this is off topic...sorry for the vent.

Altering someone else's notes is totally against the law. If there is a coroners case and your notes don't match what you're saying you're in big trouble. However - another people have said, if someone else alters your entry there will be a 'last modified by' and the date it was modified in the file information notes

OK...this is under SNF, I am thinking the typical SNF. I don't think you have to worry about someone hacking the system to delete the note without leaving a trace. But thanks for bringing the topic about what IT can do. I found it very informative. I kinda knew they could do things because I worked for an insurance company and everything was on computer and sometimes things just "disappeared".

I'm so glad I am not the only one with this problem!

I had a lady who developed two large pressure sores to the back of both heels- and dutifully put them in the system.

Two days later, the 'wound nurse' had come in, deleted BOTH of my entries, and put in the system that this (non-ambulatory) woman had aquired abrasions to her heels, from (fictional) shoes, that the (never, ever, ever present) family had brought in.

I was furious, and pitched a fit for about two weeks. No one ever bothered about it, so eventually I gave it up.