Recently a patient and family member questioned me what their physician was saying about the case, we reviewed the notes together with the permission of the patient.
Both the patient and the family member who intentionally stayed at the patient's side to act as an advocate denied that the physician had been in to the patient's room that day even though there was a complete head to toe assessment with problem list and plan.
The patient now stated that since I am aware that there is documentation that they say is fraudulent I am being held accountable by them to report the incident, which after confer with the house supervisor on a weekend I reported to the unit manager.
I have been questioned multiple times regarding this incident and the issue continues to be the discussion with the family not the fraudulent documentation of the MD. I feel like my job is in jeopardy now even after a conversation with my manager.
Will human resources or any other pathway be helpful in preserving my position. I will be completing my BSN in December and will have more flexibility after completion of my degree to change facilities.
You let that family manipulate and use you for whatever their agenda is! How do you know for 100 percent sure that there was not a visit that day? MDs can make very short visits and patients are often medicated,sick and lose track of the day and time and even time of day. They can even copy and paste plans of treatment,problem lists and other date with just a few clicks of the mouse. I would have never got cozy and shared that chart. I would have referred them up the chain of command and let them deal with their perceived problem. Does this family have an agenda to sue or create problems? I guarantee if they do they will not be helping you pay your bills if you lose your job.
I've had many situations over the years in which clients stated that they hadn't been seen by the physician when I knew for a fact that they had -- I had walked them down to the physician's office (this was in inpatient psychiatric settings) and watched them go through the door and sit down with the psychiatrist (I didn't know what they and the psychiatrist had talked about, but I darned sure knew that they had seen the psychiatrist), or I had walked the physician to the room and watched the physican enter the room to see them, or seen the physican come out of the room and ask me a question about the person -- and, then, later in the day, people would claim that they hadn't seen the physician that day. It happens, folks. People are medicated, drowsy, they get their days mixed up, whatever. I would never assume that, just because some said s/he wasn't seen by the physician that day, that s/he actually wasn't seen.
I've had many situations over the years in which clients stated that they hadn't been seen by the physician when I knew for a fact that they had -- I had walked them down to the physician's office (this was in inpatient psychiatric settings) and watched them go through the door and sit down with the psychiatrist (I didn't know what they and the psychiatrist had talked about, but I darned sure knew that they had seen the psychiatrist), or I had walked the physician to the room and watched the physican enter the room to see them, or seen the physican come out of the room and ask me a question about the person -- and, then, later in the day, people would claim that they hadn't seen the physician that day. It happens, folks. People are medicated, drowsy, they get their days mixed up, whatever. I would never assume that, just because some said s/he wasn't seen by the physician that day, that s/he actually wasn't seen.
Patients and family make this claim often and while I would guess it has happened on occasion I can't imagine a provider falsifying that they actually saw a patient although it is very likely their assessment was a quick head pop in the door "hey how are ya today?". Does your facility have cameras? That is the beauty of psych, my every move is filmed.
I agree there is no way I would be comfortable reviewing a chart with a patient. At the facilities where I work they have to request them from medical records and go through the proper channels. Anyone who gave a patient access to their chart especially since it has caused a hassle for the hospital and a physician would likely result in the nurse being terminated.
Where I work, there are only two options for patients to review their records or chart. The patient has to formally request their records through the medical records office or if they want to review their chart while in the hospital the attending physician must be present. I recently had a situation in which the patient and family members were adamant about reviewing the patient's chart before her discharge. The attending was not in house anymore, yet they kept insisting they had a right to view her chart before d/c. I had to get my charge nurse involved and it wasn't a pleasant situation (they made threats, etc.), but we only gave them the paperwork to request her records.
I've had many situations over the years in which clients stated that they hadn't been seen by the physician when I knew for a fact that they had -- I had walked them down to the physician's office (this was in inpatient psychiatric settings) and watched them go through the door and sit down with the psychiatrist (I didn't know what they and the psychiatrist had talked about, but I darned sure knew that they had seen the psychiatrist), or I had walked the physician to the room and watched the physican enter the room to see them, or seen the physican come out of the room and ask me a question about the person -- and, then, later in the day, people would claim that they hadn't seen the physician that day. It happens, folks. People are medicated, drowsy, they get their days mixed up, whatever. I would never assume that, just because some said s/he wasn't seen by the physician that day, that s/he actually wasn't seen.
Seriously. I've had enough patients swear to my face that "the nurse who was here yesterday [me] said [thing I didn't say]" or "I've been here five hours and I still haven't seen a doctor! [they've been here one hour, seen the doctor, and had a full workup]." Sometimes they really believe what they're saying (confused, drowsy, medicated) and sometimes they're manipulative. Either way, I wouldn't assume that the doc was falsely documenting just because of what the family said.
Where I work, there are only two options for patients to review their records or chart. The patient has to formally request their records through the medical records office or if they want to review their chart while in the hospital the attending physician must be present.
Raise your hand if you know any provider with the time or inclination to open this can of worms with a patient? :)
The hospital needs to change this option, its pointless and gives the patient something to argue about. If the only option is requesting it from medical records it prevents this aggravation for the attending, the nurse and also the family.
There's nothing unethical about it. the system is designed so that only people who should have access to the chart, do. There are things that keep me up, but this sure isn't one of them.
Exactly. Suppose I am reviewing a note in the chart with a pt./family member (I never would, but let's say I did), and the doctor makes the statement "given the XYZ findings I strongly suspect malignancy." Now I am stuck in the position of having to explain to the patient that the may have cancer. No thanks. If they have questions about a doctor's note, refer them to that doctor.
Plus, as others have said, just because a pt./family member swears the doctor was never in, that does not make it true. I had a patient tell me "it has been 3 days since I saw my cardiologist...where is he??" Well, it turns out that "her" cardiologist was on vacation and she was seen all 3 days by that cardiologist's partner. There are also cases of someone just not remembering that his/her physician was in.
I have gotten lots of different notices regarding me as a patient being able to access my records at different hospitals in the area. I'm thinking this has to do with HIPAA. One of the hospital systems has an access to your medical chart for certain things, one of those things is not physician notes. I know in some types of paperwork I have been told if I want access to my medical record I can have it but I must contact such and such a person and I can get most everything but I don't get access to the physician notes. I know I have read that. The places I have done clinical, nurses were not allowed to show the patient or their families what came up in their computer system. I don't know how every hospital system works but I thought this was all through HIPAA. I was interested in looking at one of my records at one point a few years ago about something that one doctor missed and pretty much dismissed my symptoms and I had almost died a few days later from a PE. This was back in 2008 or 2009 and that is what I remember getting from my research. And they update the HIPAA stuff every year, but I'm almost positive what I read and what my experience has been.
I think the PP hit the nail on the head that these people manipulated you for their own personal gain. It's awful the things people will do these days and how they will take anybody down with them. Unfortunately, that may be you. I'm glad you went and talked at least to your supervisor right away, but when the hospital admin gets a hold of this, you may not be there much longer.
Always make sure you know your hospital policy. I also think you should call your malpractice carrier and see what your liability is. I don't think you are responsible if these people wanted to file a lawsuit, I just think you may be out of a job.
As a pt I can log on and look at lab results, meds etc.. but NOT the provider's or nurses notes. As I sit and think I understand and am ok with it. I can only imagine how a layperson looking for a quick buck could pick notes apart. All the more reason for EMR.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I'm glad I've never worked at any of these places where inpatients can only get information about their care by making an appointment with medical records. I'm not sure how that meets the legal requirement that patients have timely access to all information related to their care, much less the ethical requirement that should be preventing nurses from tolerating such a rule.
I've never worked anywhere that patients were allowed "timely" access to all information. There's always been a process including an appointment with medical records and a provider to sit with them while they read the chart to make sure they understood what was written. This protects the nurse as well.
Specializes in Complex pedi to LTC/SA & now a manager.
I've never worked anywhere that patients were allowed "timely" access to all information. There's always been a process including an appointment with medical records and a provider to sit with them while they read the chart to make sure they understood what was written. This protects the nurse as well.
Timely does not mean instant. Timely is usually 5-10 business days with a maximum charge if copies are needed but the charge for copies must be reasonable and notified in advance.
I've had nurses print out copies of labs after the physician reviewed the results. I've gotten copies of test results but to review progress notes (not that I would personally want to) required a formal request to medical records as any progress notes & dictated reports had to be reviewed for accuracy and edits before release.
I've never worked anywhere that patients were allowed "timely" access to all information. There's always been a process including an appointment with medical records and a provider to sit with them while they read the chart to make sure they understood what was written. This protects the nurse as well.
How does that protect nurses?
I can't see how it's possible to both limit a patient's access to their own information, and at the same time ensure that patients are fully aware of their conditions, labwork, etc so that they can make fully informed decisions. Those two things seem contradictory.
Exactly. Suppose I am reviewing a note in the chart with a pt./family member (I never would, but let's say I did), and the doctor makes the statement "given the XYZ findings I strongly suspect malignancy." Now I am stuck in the position of having to explain to the patient that the may have cancer. No thanks. If they have questions about a doctor's note, refer them to that doctor.
Plus, as others have said, just because a pt./family member swears the doctor was never in, that does not make it true. I had a patient tell me "it has been 3 days since I saw my cardiologist...where is he??" Well, it turns out that "her" cardiologist was on vacation and she was seen all 3 days by that cardiologist's partner. There are also cases of someone just not remembering that his/her physician was in.
How are they going to "have questions about a doctors note" if they aren't allowed practical access to the note? How is it better for a patient to not know they need to have a potential malignancy that the doctor neglected to tell them about followed up on?
elkpark
14,633 Posts
I've had many situations over the years in which clients stated that they hadn't been seen by the physician when I knew for a fact that they had -- I had walked them down to the physician's office (this was in inpatient psychiatric settings) and watched them go through the door and sit down with the psychiatrist (I didn't know what they and the psychiatrist had talked about, but I darned sure knew that they had seen the psychiatrist), or I had walked the physician to the room and watched the physican enter the room to see them, or seen the physican come out of the room and ask me a question about the person -- and, then, later in the day, people would claim that they hadn't seen the physician that day. It happens, folks. People are medicated, drowsy, they get their days mixed up, whatever. I would never assume that, just because some said s/he wasn't seen by the physician that day, that s/he actually wasn't seen.