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Documentation altering

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BabetteR BabetteR (New) New

Specializes in Mental Health, Case Management. Has 20 years experience.

I am a nursing supervisor in a Methadone clinic and work with several counselors. One of the counselors is very unprofessional. I discovered that she is altering my admission assessments. They are still in paper format. She is putting information in the assessment about patients that isn't true. Saying that they have numerous psychiatric hospitalizations when they have only been to the emergency room for a panic attack related to withdrawal. The question is have they had any psychiatric hospitalizations, to which I answered no. She feels that an emergency room visit constitutes hospitalization. I have signed the document and she proceeds to go back and alter the documentation after I have completed the forms. I have reported this to my director, but she has a business degree, not a health care degree. I don't know how to address this situation. Quitting my job isn't an option, I really like the job, but don't know stress the importance of another person not being able to alter my assessments. First of all this is illegal and what she is putting in my assessment is not factual.

You state you are the nursing supervisor...have you approached this individual about this issue? Is there another person higher up than the director that you can report this to?

BabetteR

Specializes in Mental Health, Case Management. Has 20 years experience.

You state you are the nursing supervisor...have you approached this individual about this issue? Is there another person higher up than the director that you can report this to?

Yes I have said something to this person, but she just ignores me. She has a tendency to start yelling which makes it a very hostile work environment.

If you are a supervisor, then I would meet with the director and create a plan. Not on a thought process that your supervisor do something about it, you. I would notify your malpractice insurance for guidance as well. If your parent company has a complinace, risk managment, and or ethics department they should be made aware, and may guide you differently, however, just some general thoughts:

I would make it abundantly clear that the counselor have their own notes, intake, assessment paperwork. That is where they put whatever the heck they want to, and they are responsible for backing it up. At no time is the counselor to add to your nursing notes. If policy allows, the counselor can add to the general notes "patient states that they have gone to to ER "X" amount of times for symptoms r/t withdrawal", for instance (and give examples of what would be appropriate and where).

That if the counselor continues to alter your or any other nurse's documentation, that you will have no choice but to discipline them, up to and including termination. This is the altering of a legal document. Be very clear and timelined as to the paperwork that IS appropriate for the documentation, and what is not. Give the counselor the opportunity to right themselves. Be sure you document all of this that occurs in your meeting, and draw up a specific written plan for improvement.

Additionally, I would make clear that if the counselor's reaction to all of this is "yelling" and otherwise acting wildly inappropriate, that also will require a discipline process.

Make sure that every counselor is aware that altering the notes of a nurse is not appropriate under any circumstances. Give them the resources and tools to be able to document what they need to on their own paperwork.

But be sure to contact your malpractice insurance.

Let us know how it goes.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Yes I have said something to this person, but she just ignores me. She has a tendency to start yelling which makes it a very hostile work environment.

Start making book for progressive discipline.