disappearing nurses notes!

[ltcnightrn]

Is it legal for the DON to make pages of nurses notes ( paper charting) disappear ? I documented 2 pages of notes on tuesday on a resident about the resident complaining of pain and not recieving prompt calls back from the md and pharmacy. It took 4 hours to get the pain medicine. And when I came in to work today all my charting was gone. The other nurse I work with said the DON has the tendency to make certain charting "disappear " if she does nt like its contents. Is this legal ?

[linearthinker, DNP, RN]

It isn't just LTC. I have known it to happen in my hospital when the risk mgmt people don't like comments that highlight deficiencies. We have one doc in particular who tells it like it is in his progress notes ("not enough nurses to take care of this patient and that is why he is developing pressure ulcers," or "respiratory therapy doesn't like to do pulmonary toilet and gets mad at me when I order it and now this patient is developing vent related pneumonia.") , they get "lost" all the time.

[morte, LPN, LVN]

first, you only have that nurse's word that it is the DON doing the deed...it may be that it is that nurse doing it and not the DON....good luck

[AtomicWoman]

For those who are suggesting this person make a copy of her nurses' notes (which believe me, I am sympathetic with), I have a question. I have been told that I cannot take anything with me that has patient identifying information. All patient summaries, printouts of MARs, etc. must be put in the shredder at the end of the shift to maintain patient confidentiality. So if I were to make a copy of my nurses' notes, where would I keep them? Just wondering, as this is an issue I have seen come up on AN before. OP, you have my sympathy. If someone removed or edited my notes, I would be pretty upset.

[caliotter3]

Have seen this at facilities where I worked, have also seen where nurses were asked to rewrite notes. You have to figure out whether your need for this job overrides your desire to protect your license. No urging on your part will get her to stop doing this if she thinks she is helping herself. Your best bet is to go above her head if you could do so without retaliation. Usually not the case.

[TakeOne]

first, you only have that nurse's word that it is the DON doing the deed...it may be that it is that nurse doing it and not the DON....good luck

Further, this is an example of how "chart wars" get us all into trouble. Chart wars start when one caregiver writes something derogatory/inflammatory/unsubstantiated in the notes, others act to defend themselves, the situation escalates and something must be done. It looks hinky but it's not unheard of for a department head to use the notes in question as an example of how it's NOT to be done and ask the caregivers to rewrite their entries using more factual, less opinionated, less accusatory, more germane language.

I once worked at a SNF where a nurse who had been there since Moses was a pup disliked the newly-hired ADON and Staff Development Coordinator. She would sit in the DON's office (they were good friends) and gripe and complain about this, that and the other thing about them without end, and at first the DON took the concerns and complaints seriously. After a while, as the complaints went on and on and became increasingly personal, the DON had to admit something to herself and had to take a look at the complainer's work. She observed nothing of concern, until the day that both the ADON and the SDC met with her in the Administrator's office and showed her the notes from several residents' charts in which the complainer had accused them by name of being too inexperienced to handle their jobs and therefore responsible for incompetently supervising the CNAs who had been involved in recent resident falls. When confronted with the documentation, the complainer explained to the DON that she had no intention of apologizing for the chart notes. She didn't feel she'd done anything wrong as she was sure her statements were correct. She also stated that it was her intention to "run them out of here," and she knew that the DON as her very good friend would protect her. As far as I know, she still believed that all the way out the door when she was fired and escorted out of the building.

[nursenow]

I am sitting here wondering what situation would cause me to use two pages charting about a slow MD/pharmacy taking four hours to supply pain meds. I really can't. If it was that bad, I would call an oncall MD and tell him/her I need to transport a patient to the ER because we are unable to control his pain. If the MD refuses, just make a short entry about it in the nurses notes, transcribe it as a T.O. on the physicians orders page and be done with it. In order to throw away your entry in the physicians orders the DON would have to throw away all the other orders on that page also. If you are not allowed to write T.O.s where you work just make a one paragraph entry with only the relevent facts and call it quits.

Only twice have I been unable to get hold of an oncall MD. When I demanded to be put through to another doctor and told the aswering sevice I absolutely have to talk to an MD (after they insisted there was no one available) it took about 60 seconds for another MD that wasn't even on call for mine to call back. I have never made a two page entry for anything including work place violence, elopements, abuse, --nothing.

It is possible removing that entry protects you as well. did you really take ALL action available to you to provide for your patient? Did you call your supervisor (the DON) about a situation you were not able to resolve?(), how many times did you call the pharmace/ MD. What did you tell them, What else did you do to relieve the patients pain? In your charting were you blowing off steam or sticking to actual facts and not perceptions and opinions?

I have had my DON ask me to rewrite two different entries and after she explained why I was happy to do it. Those rewrites included other nurses having to redo theirs also. My entries made both me and the facility look bad were we to go to court.

But in the end I have to say I totaly agree that what the DON did is illegal. It does happen in LTC/SNFs though. Find another job BEFORE you report it because you are going to need one.

[nursenow]

For those who are suggesting this person make a copy of her nurses' notes (which believe me, I am sympathetic with), I have a question. I have been told that I cannot take anything with me that has patient identifying information. All patient summaries, printouts of MARs, etc. must be put in the shredder at the end of the shift to maintain patient confidentiality. So if I were to make a copy of my nurses' notes, where would I keep them? Just wondering, as this is an issue I have seen come up on AN before. OP, you have my sympathy. If someone removed or edited my notes, I would be pretty upset.

If you made copies of a patients information and kept it you would be as guilty as the DON. You would be breaking facility and probably federal rules. This is another great example of why everyone nees to go to electronic charting. If your DON deletes something there is a record of him/her doing that and even if something has been deleted it can still be recovered.

[lindarn]

I completely agree with poster #8- make copies of nurses notes in situations like this. If they disappear, you have no proof that you wrote notes on your patients.

I would also make copies of incident reports, because, they too, have a habit of disappearing if/when, they could incriminate management, administration. Forget about the, "don't make copies of stuff like this, because you could get in trouble".

Now what is going to happen when there are no nurses notes in the patient's chart from you.

CYA!!

JMHO and my NY$0.02.

Lindarn, RN, BSN, CCRN

Somewhere in the PACNW

[OttawaRPN]

What do you all mean by "rewriting" notes? Does your legislation not mandate that you strike one line through the entry and write "error" beside it? The notes are still legible, (never scribble out, erase or write in pencil) which means nobody can cover-up anything already written.

I once got singled out for making my workplace "look bad" by subjectively writing certain complaints a resident had in relation to her care. I was sure to use quotes indicating these were the resident's words and not my observations, but still got my wrist slapped. They tried to berate me and intimidate me into admitting wrongdoing but I was having none of that. As if I give a damn whether my charting opened them up for a potential lawsuit, I hold no loyalties to any of my jobs, I am there for the best interest of the patient.

[tyvin, BSN, RN]

What do you all mean by "rewriting" notes? Does your legislation not mandate that you strike one line through the entry and write "error" beside it? The notes are still legible, (never scribble out, erase or write in pencil) which means nobody can cover-up anything already written.

I once got singled out for making my workplace "look bad" by subjectively writing certain complaints a resident had in relation to her care. I was sure to use quotes indicating these were the resident's words and not my observations, but still got my wrist slapped. They tried to berate me and intimidate me into admitting wrongdoing but I was having none of that. As if I give a damn whether my charting opened them upit. for a potential lawsuit, I hold no loyalties to any of my jobs, I am there for the best interest of the patient.

Yes this is how; and when rewriting in the progress notes indicate "late entry" and date it the day you write. Also the one post that advised to chart in the other areas (back of the MAR sheets, TAR's etc...excellent.

[defensemech]

the DON has no right to attached or detached such legal documents because she didnt work direct contact with the patient, even if a staff committed mistake, she will just review the documents and after that she should put back the documents, that DON for sure has something crap going on in her mind, every institution have the same nursing policies regarding documents

[mswhitern]

Wow...like someone said earlier, now you are just as guilty because you know - even though you truly did your job and you did it right. You really need to start looking else where because they - the company - does not have your best interest, not the patients best interest at heart.

I hope this all works out for you, but please make sure you ask your God for some direction in this matter. You are in a tough situation and your license is on the line.