Documented note for a coworker RN

Nurses General Nursing

Published

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!

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.

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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.

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Specializes in Pediatrics, Pediatric Float, PICU, NICU.
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.

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Specializes in ICU, LTACH, Internal Medicine.
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.

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Specializes in Clinical Pediatrics; Maternal-Child Educator.
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.

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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.

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You wrote false documentation and now you’re upset you got caught for it? Never document something you didn’t do yourself. Consult with a nurse specialist attorney because you're in serious legal trouble.

You should have alerted your coworker to the fact they forgot to write the note so they could go back and do it themselves.

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Specializes in Med-Surg., LTC,, OB/GYN, L& D,, Office.

As I recall, new admissions require the completion of an assessment form as well as a written entry into the medical record, the chronological occurrences significant to that patient for a particular stay..

If you completed the assessment begun by your coworker I believe that it would be acceptable to initial those comments made by you and sign your name and the coworker do the same for his/her portton.

However, if no other notation was made, and you took it upon yourself to complete a document with little or no firsthand knowledge, the consequence of that act increases.

In any case I believe some form of corroboration is called for Via the coworker

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