Documenting for someone else

[EquusAnonymous]

Sigh...I'm being asked by my DON to document immunizations given by MAs who are no longer with our company and who failed to document and submit them. I am completly uncomfortable with this. I was told today that if I don't know if it was given I need to look at the doctors note to determine if it was given, if I'm still not satisfied I need to contact the parents of the patients and ask if the patient received the vaccinations. She told me all I have to do is document that it was given and also document what ever MA I presume gave it, gave it. The rational is that the patient needs to have a correct MR so that they don't end up having to get the same immunization. The problem is I can't guarentee what MA actually gave the vaccination as there is no documentation to tell me-I can tell who roomed the patient but I can't tell if another MA jumped in and gave the immunization and I can't be 100% sure the immunization was actually given in the first place. A majority of the patients will have a form scanned in the chart with an order/document that states that at that visit with those imz ordered they are now up to date on their IMZs-but again there is no signature by anyone that actually would be giving the vaccines, only the doctors signature at the bottom that should signafy that they ordered those vaccines and they were given. I can contact the parents but so many parents can't tell you how many immunizations their child got on any given day (and I'm looking at a 5 month time span) let alone what they were.

Does anyone have any advice on what to do or resources that I can go to?

Thank you!

[jadelpn, LPN, EMT-B]

If you are going to stay with this job, get malpractice insurance asap.

With that being said, I would go back and suggest a "problem solving" technique would be that you will in fact get any information you can on the kids in question regarding their vaccinations--lot numbers, comparing the check off's that the vac was taken on any given day, against the kids who were due to recieve them, if parents have copies of the little books with the vacs listed as given, even the local schools should have vaccine records on the kids. You will present all of this compiled information to the DON, who can then document as she sees fit.

I would not, under any circumstances document that "MA Such-and-so" gave any vaccine. Because you do not know if they did or did not. You have no idea where the vaccine was given--and there has been more than one vaccine given in an incorrect site, and parents do notice, and will take it to the next level. (ie: a parent I know of was going to sue because an MA gave an immunization in the upper arm of a small child, it developed a cellulitis, and they were less than thrilled when a "knot" formed....after an ER visit due to the cellulitis). There are many parents who decline some vaccines at certain times....a mess of epic proportions that shouldn't fall on you to fix.

If you again are staying at this place, I would see about a nurse only vaccine policy where MA's do not give vaccines. This way, it will be all documented correctly by the same person who is signing off on the vac. and you as a licensed person can in no way be held liable for what an unlicensed person does or does not do.

Your DON is in a panic, as I am quite sure that with school opening really soon, parents are wanting their kids records. The kids can not go to school unless their records reflect up to date immunizations. As a manager, this is her thing to fix, not to delegate to someone who was not there to witness any of this. That is why she is paid the big bucks.

What you can do is offer to compile as much information as you can for her to do so. If she declines, then I would give my notice. But not without sending a copy of the email to the BON, contacting the state (as some of the vacs are given out by the state) and also can be insurance issue (as public assistance insurance ie: state health plans) also send certain amounts of vaccine--

What a nightmare, and I am so sorry you have been put in this situation. Just not right on a number of levels. Let us know how it goes.

[icuRNmaggie, BSN, RN]

Were you this MA's direct supervisor? Were you even there when these vaccinations were given? If not stay out of it.

Speak to the MD privately. I would say something along the lines of "many of our patients vaccines were not documented by the MA and I was asked by DON to find a solution. What should I do?"

Write down his response. Protect yourself. False documentation on a Medicaid or Medicare pt is fraud.

[nurseprnRN, BSN, RN]

Were you this MA's direct supervisor? Were you even there when these vaccinations were given? If not stay out of it.

Speak to the MD privately. I would say something along the lines of "many of our patients vaccines were not documented by the MA and I was asked by DON to find a solution. What should I do?"

Write down his response. Protect yourself. False documentation on a Medicaid or Medicare pt is fraud.

One correction-- have him write down his response.

[nurse4ever08]

Only document what you observed and know happened. Is there a state vaccine register you look up the patient information and get it there ? The state I am in uses one that is web based and can be accessed by peds clinics and hospitals. After the vaccine is given, the registration is updated and current copy prints out for the parent

[icuRNmaggie, BSN, RN]

Forward the work emails to your home account before they are removed.

[Esme12, ASN, BSN, RN]

Because we do daily inventory I can determine the lot and exp that was available that day. The things I can't determine for a fact is the person that gave the vaccine and if the vaccine was given for sure. My DON seems to be set that I will be doing this. Her email to me pretty much stated that I needed to problem solve and get it figured out and get it done.

If you have malpractice call them and ask for advice. Call your BON and ask them for advice.

Here are my thoughts. You cannot identify which patient got which immunization in that given lot number that day. You cannot verify if the patient got the immunization at all. You do not know which MA gave the immunization to which patient. If your DON wants them documented she can document it herself. This would be one instance I would stand my ground even if it meant I lose my job.

[workinmomRN2012, BSN]

save her e-mail as proof of what you are being asked to (illegally) do. Maybe tell her you would feel more comfortable if you first called your BON and ran it by them to make sure it's okay

AWESOME!!!

[workinmomRN2012, BSN]

NO WAY!!!

I agree.....save her e-mail as proof of what you are being asked to (illegally) do. Maybe tell her you would feel more comfortable if you first called your BON and ran it by them to make sure it's okay

Let us know how you handled this situation and good luck! That's a tough spot to be in.

AWESOME response!!!

[toomuchbaloney]

Is the DON an RN?

Refuse to document in the patient record (in a polite and professional but very assertive way).

Reply to her email (creating a thread of conversation) in which you provide some facts and research for the DON including any policy, procedure, or law which addressess the concept of documenting something that you did not do to a patient you did not see.

Include the physicians as a cc in the conversation as in many states they are the only ones who may supervise MAs.

Do not be combative but be firm and insistent that you are NOT going to document anything in the patient records regarding that MA activity.

Be prepared to lose your employment.

Gather all communications from the DON regarding this request and visit an attorney if you do.

Good luck.

[icuRNmaggie, BSN, RN]

If you are even peripherally involved in a CMS investigation of Medicaid or Medicare fraud you will be unemployable at any facility that provides services to Medicaid and Medicare patients. Forever.

Somewhere on the web there is a database of every healthcare worker who has been convicted of CMS fraud. This is one of the first things that HR looks at in every background check.

[toomuchbaloney]

If you are even peripherally involved in a CMS investigation of Medicaid or Medicare fraud you will be unemployable at any facility that provides services to Medicaid and Medicare patients. Forever.

Somewhere on the web there is a database of every healthcare worker who has been convicted of CMS fraud. This is one of the first things that HR looks at in every background check.

Which brings up a very good point.

If you are terminated for refusing to comply with this unreasonable request and you are aware that the documentation was completed by another, CMS might be interested in knowing about that illegal and unprofessional activity.

[icuRNmaggie, BSN, RN]

If a child becomes ill and possibly permanently disabled by for something that he was supposed to be vaccinated for the clinic can say "equs signed that she gave the vaccine.." You will definitely be thrown under the bus in that situation. I think you need legal counsel.