False Documentation

[ohionurseltc]

Myself and and a fellow nurse had our documentation removed and a totally false nurses note put in its place. My question is who is responsible for reporting this. We were told the "order" came from the administrator and the unit manager had another floor nurse write up the false note. Obviously I'm sketcky about going to the administrator. What do I do?

[salvadordolly]

What were their reasons for doing this? I have asked nurses to modify their own charting to more accurately reflect a situation, but have never had another nurse just make up a replacement note.

[RLtinker, LPN]

I don't understand the reasoning that a nurses documentation could be edited by someone else besides that particular nurse. Even in nursing school we are taught never to leave spaces when we document on hard charts, and with the reasoning that someone could later add something incriminating. Yet administrators can alter or remove our electronic documentation that we are responsible for. After all, a chart is legal document is it not? And as in the first rule of nursing, if it wasn’t documented it never happened.

Just out of curiosity what exactly did they remove and what did they replace it with?

[Jory, MSN, APRN, CNM]

What were their reasons for doing this? I have asked nurses to modify their own charting to more accurately reflect a situation, but have never had another nurse just make up a replacement note.

When I was a new grad, I was asked to rewrite a note because what I wrote was incorrect, but it did accurately reflect the events more accurately, so I did.

However, the keyword here it was brought to my attention and I wrote it.

However, someone cannot chart what they didn't do or see. I would find out if they signed your name to it and I would report it.

[nurseprnRN, BSN, RN]

I'm betting that there is some sort of legal action in the breeze, or else perhaps your note was incomplete for purposes of reimbursement coverage, and the administrator wants to do some quick butt-covering. Either way, if anyone wrote a note and signed your name to it, that's wrong. Or did the other floor nurse sign her own name to it? Can you ask him/her?

I'd report my suspicions to the state department that licenses your facility if you can't get better information that reassures you.

[she244]

I was out of the office and a physician did a procedure that I usually assist him with and do my own documentation of my part of the procedure. Once I came back to work I checked the charts and saw that he had copied and posted from a previous note my part of the procedure that had my name signed to it. I went to my supervisor to report that this should not have happened. I was told to tell him to removed the note and to try to pick my battles. Now I document, print out my note and lock it up so should something happen I have proof since the record is dated and stamped. And I cover myself in every respect. I have become very legalistic.

[jadelpn, LPN, EMT-B]

Go to risk management. Parent company's ethics hotline.

If it is electronic, it is not always possible to do without some sort of footprint.

If it is paper charting, an investigation as to who had the patient in question when, whether the nurse who re-wrote the notes was even working on the day in question.

This would be best handled by risk managment.