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Documented note for a coworker RN

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by FloatDaddy FloatDaddy (New) New

In our very small unit, we work as a team generally. My coworker clocked out after a change of shift admission and did not write an admission note. I wrote a very brief one based on my knowledge of the patient from team discussion.

I am now being accused of falsifying documentation by my DON, and am meeting with HR and union rep in 5 days.

Please help if you have any thoughts!

Been there,done that, ASN, RN

Has 33 years experience.

Do not go to that meeting without a lawyer.What you are accused of is a felony. Notify your malpractice carrier as well. Were you present in the patient's room that day?

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

It would be one thing if the coworker called in and dictated a note that you entered with “Per phone call from...” (still a little sketchy) vs you simply entering a note based off of what you heard in team report. Agree with above- bring someone with you who will be in your corner.

What is this about? Is it because you didn't personally gather assessment information prior to making a note? Or because your DON thinks that an admission summary can only be made by the person on duty when the patient rolled in?

I don't understand. This sounds like trouble-making.

Nurse Beth, MSN

Specializes in Med Surg, Tele, ICU, Ortho. Has 30 years experience.

If you documented findings without assessing the patient, I'm sorry to say, you are most likely in trouble.

Not sure how you can present this otherwise.

Daisy4RN

Specializes in Travel, Home Health, Med-Surg. Has 20 years experience.

Depending on the circumstances I would definitely contact an attorney. Was the "brief" note simply saying pt arrived and you charted what you actually knew to be true, or did you chart a full assessment. If you charted here say and didn't document "per (other RN)" you may have a problem.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

3 hours ago, JKL33 said:

What is this about? Is it because you didn't personally gather assessment information prior to making a note? Or because your DON thinks that an admission summary can only be made by the person on duty when the patient rolled in?

I don't understand. This sounds like trouble-making.

The OP did not admit or access the patient, did not establish relationship, was not included into treatment team, but still wrote "very short" admission note from the info that was overheard from a team huddle or something like it.

It is classic false documentation case and, yes, however stupid it sounds, it is, at least on the paper, a felony and reportable occurence, plus HIPAA violation. I cannot imagine what in the Universe might prompt the OP to do that except of that blindly task-oriented attitude of "iamjustdoingmyjobasanurse".

Sorry, the OP needs a lawyer and likely more than one if he or she would like to continue holding nursing license (or any other professional license, for that matter) in any shape, color or quality.

Frankly, this (appropriately moderated) topic should be in the list "mandatory reading for all nursing and pre-nursing students: things which must not be done, ever"

Edited by KatieMI

I guess I assumed the OP took over patient care and there were still a couple of items to wrap up from the admission (such as this summary, whatever that consists of). Maybe that's not the case. But if it is, well, patient care is often handed off with admissions partially or mostly (but not entirely) completed. If it is an on-coming nurse involved with the patient then IMO which of the two nurses writes a summary about the fact that the patient has arrived and been admitted for the care and tx of xyz seems pretty much irrelevant.

I'm pretty particular and aware of issues surrounding stuff like this usually, but I just don't see the big deal here unless the OP was a random staff who happened to notice that this most crucial task (🙄) of writing an admission summary was not done and so wrote some things down even though otherwise uninvolved. If the OP was just completely uninvolved then I agree with the other comments = not good.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

7 minutes ago, JKL33 said:

I guess I assumed the OP took over patient care and there were still a couple of items to wrap up from the admission (such as this summary, whatever that consists of). Maybe that's not the case. But if it is, well, patient care is often handed off with admissions partially or mostly (but not entirely) completed. If it is an on-coming nurse involved with the patient then IMO which of the two nurses writes a summary about the fact that the patient has arrived and been admitted for the care and tx of xyz seems pretty much irrelevant.

I'm pretty particular and aware of issues surrounding stuff like this usually, but I just don't see the big deal here unless the OP was a random staff who happened to notice that this most crucial task (🙄) of writing an admission summary was not done and so wrote some things down even though otherwise uninvolved. If the OP was just completely uninvolved then I agree with the other comments = not good.

To make a big deal or not out of it is totally up to OP's administration, unfortunately.

We can love or hate it but accepting patient without that "taking assignment" click for 30 min while another nurse takes a break and perusing the chart at that time is, by the letter, a fact of accessing patient's info without establishing relationship and therefore can be seen as HIPAA violation. Usually nobody cares much about it, although at some time some facilities choose their next internal battle to target "potential HIPAA violators". But there are repeated stories about some celebrity admitted in a hospital and some people nicking into his chart and being fired and reported for that, even if they had kind of reasonable explanation of why they did it.

We may never know exact details of what really happened but what is clear enough is that the OP has got very deep in hot water.

JadedCPN, BSN, RN

Specializes in Pediatrics, Pediatric Float, PICU, NICU. Has 15 years experience.

32 minutes ago, JKL33 said:

I guess I assumed the OP took over patient care and there were still a couple of items to wrap up from the admission (such as this summary, whatever that consists of). Maybe that's not the case.

I'm basing it off of OP's statement "My coworker clocked out after a change of shift admission and did not write an admission note. I wrote a very brief one based on my knowledge of the patient from team discussion. " That does not sound like she took over patient care at all. I agree with you though, if she did take over patient care then that is a completely different story.

Edited by JadedCPN

3 minutes ago, JadedCPN said:

"My coworker clocked out after a change of shift admission and did not write an admission note. I wrote a very brief one based on my knowledge of the patient from team discussion.

I read that and it seemed ambiguous (as in: I got report. While reviewing the documentation I noticed the summary hadn't been done and I did it based on the info I got in report without further evaluating the patient). I figured that reviewing the documentation was how the OP realized the summary hadn't been done in the first place. But maybe the fact that the summary wasn't done was passed on in report. Who knows.

Maybe my mind automatically went that way because I can't imagine caring about what documentation a peer did or didn't do if I'm not involved at all with the patient.

Sorry for the tangent. Carry on! 🙂

8 hours ago, Nurse Beth said:

If you documented findings without assessing the patient, I'm sorry to say, you are most likely in trouble.

Not sure how you can present this otherwise.

I believe this is the crucial point.

22 hours ago, KatieMI said:

We can love or hate it but accepting patient without that "taking assignment" click for 30 min while another nurse takes a break and perusing the chart at that time is, by the letter, a fact of accessing patient's info without establishing relationship and therefore can be seen as HIPAA violation.

Can you even get into a patient's chart without clicking that? In my hospital, I have to click a reason (registered nurse, covering nurse, or chart review) before I can see anything in the patient's chart. Even if I had the patient yesterday, the chart will still be greyed out for me until I "establish relationship" today. Similarly, if nurse Jane asks me to give Mr. Jones a med, I have to select "covering nurse" before I can access his MAR.

JadedCPN, BSN, RN

Specializes in Pediatrics, Pediatric Float, PICU, NICU. Has 15 years experience.

25 minutes ago, turtlesRcool said:

Can you even get into a patient's chart without clicking that? In my hospital, I have to click a reason (registered nurse, covering nurse, or chart review) before I can see anything in the patient's chart. Even if I had the patient yesterday, the chart will still be greyed out for me until I "establish relationship" today. Similarly, if nurse Jane asks me to give Mr. Jones a med, I have to select "covering nurse" before I can access his MAR.

I've worked with EPIC and a version of Cerner, and this was never a necessity for either of those systems unless they were marked as a "no information" patient. So for the places I've worked, you can access anyone's chart without marking a reason why.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

1 hour ago, turtlesRcool said:

Can you even get into a patient's chart without clicking that? In my hospital, I have to click a reason (registered nurse, covering nurse, or chart review) before I can see anything in the patient's chart. Even if I had the patient yesterday, the chart will still be greyed out for me until I "establish relationship" today. Similarly, if nurse Jane asks me to give Mr. Jones a med, I have to select "covering nurse" before I can access his MAR.

You can, technically, access any patient's chart at any moment, even with "restricted access" (for which in most systems you only need to click on "reason to access" and maybe re-enter your credentials. But every access to every chart is registered and, should something happens, you might be asked why you did that. And then you better have a good explanation.

Edited by KatieMI

LovingPeds, MSN, APRN, NP

Specializes in Clinical Pediatrics; Maternal-Child Educator. Has 11 years experience.

On 5/28/2020 at 2:20 AM, FloatDaddy said:

My coworker clocked out after a change of shift admission and did not write an admission note. I wrote a very brief one based on my knowledge of the patient from team discussion.

If that were the case, the appropriate thing would be to either to let the admitting nurse know that it wasn't done so that it could be arranged to do or to have the on-coming nurse write an admission note at the time of their own assessment of the patient. A lot of places allow for admission documentation to be completed up to 24 hours after the admission if necessary due to situations like this. It's not ideal and shouldn't be a common occurrence. Those who review charts are aware of occurrences such as change of shift admissions. They are not likely to fault someone for failing to put in an admission note at a change of shift admission when the on-coming nurse completes it or the writing of a late admission note (within that 24 hour period), particularly when there is evidence of other care going on - documented IV starts, medications given, lab work being collected, etc.

When I have had this happen, I simply charted the admission data for the time I saw/assessed the patient and simply put a note for the time I received report stating "Report received from XYZ, RN."

On 5/28/2020 at 2:20 AM, FloatDaddy said:

I am now being accused of falsifying documentation by my DON, and am meeting with HR and union rep in 5 days.

If you wrote the note containing any admission data that you did not directly receive from the patient or from your own assessment of the patient as if you were the one doing it, you have falsified documentation. If you wrote the note for a time of admission when you were not present on the floor or involved in care, you have falsified documentation. It doesn't matter how factual the information you provided, if you didn't do it or didn't witness it, it isn't yours to document.

On 5/28/2020 at 2:20 AM, FloatDaddy said:

Please help if you have any thoughts!

Falsifying documentation is a serious offense which could cost you your job and possibly your license if the BON is notified and their investigation concludes this. As others have said, I would not speak with anyone else except with an attorney present. Write down somewhere the facts as you recall them (without the use of patient identifiers), because if this proceeds to the BON, you may be reiterating the same information over and over and as time goes on, the memory lapses.

Take this as a learning experience. If you didn't do it, see it, or directly hear it from the source at the time it all went down - don't chart it.

beckysue920

Specializes in Psych, HIV/AIDS.

FloatDaddy, what was the outcome of this incident? I hope you were able to get it straightened out without too many problems.