I have a quick story and then a question to ask my fellow nurses... I am a wound care nurse in a LTAC hospital and have been with the same company for the past five years. Our company has hospitals all over the country. A little more than a year ago my very good friend and charge nurse with this company was promoted to CNO at one of our hospitals about two hours away. Long story short: my husband received a very nice job offer in the same city she was transferred to and, eventually, we moved and I accepted a position in the same hospital. She is now my CNO - my boss.
It is our corporate policy to take photos of any alteration of skin integrity within eight hours of admission. If the wound nurse is not available, the charge nurse is responsible and then the wound nurse reassesses the patient on their next day back. This happens quite often on night shift and weekends. We admitted three new admits the other night and the night charge nurse took photos, however, those photos were lost on the camera. The following day, I retook the photos and did my documentation as the policy states. The loss of the original photos was reported to the CNO. Two days later, while doing a routine chart audit, it was noticed again that the chart was not corporate compliant due to those missing photos. The CNO and Nurse Manager told the quality coordinator to tell me to turn off the time/date stamp on the camera, retake the photos, and then back date the documentation of the photos to the night the photos SHOULD have been taken. I refused.
Am I crazy, or is this blatant falsification of documentation? Nothing about this idea sounds good or right. Forget the fact that my "friend" has suggested this, but the legal ramifications could be BIG!!
I am asking for your thoughts, opinions and/or ideas. Should I be looking at this from a different perspective? Am I making a mountain out of a mole hill?
Nope, not at all. Everyone involved could face charges for falsifying legal documents if such a thing were to be revealed by a whistleblower (hint, hint). Your "friend" could easily throw you under the bus if such a criminal act came to light and your name was associated with it. Good call on your part to not participate.
Child ponagraphy...did I really read that? I suppose all the other people in burn units, women having breast reductions, people having sex change operations, etc... I could go on and on but, are they all really unsuspecting victims of sick staff whose motives are to take deleterious pictures of vulnerable people? Photographs are one of the true measures of proof that a wound is as stated and to be able to document progress. As Dr.s and nurses we see naked all the time; lets not get it confused.
To the OP; you are not making a mountain out of a molehill. It would be falsifying records, period. Good for you. If there is a next (there maybe lots of next times). Tell them if they want it done that way to do it themselves. As nurses we tend to attach emotion to many of our actions in the nursing world. It's a business; that's all. This may not make you popular, but people will now know you won't compromise your integrity to please your boss or anyone else.
What if a patient's wound(s) is/are in the groin area or buttock? What if the patient is a minor (underage)? Wouldn't that technically constitute child Mediaography? Anyway, I really did not mean to sidetrack or divert the tread and, if it is unwelcome, I apologize for doing so.
No apology necessary - these are great questions.
The purpose of photographing a wound or abnormality is to (1) document a baseline of the wound/burn/abnormality's appearance and (2) to definitively track the visible progress of healing. We do this for any ER patient admitted to the ICU or Medical floor with a trauma/burn/rash complaint, all post-ops, and other scenarios in which a visual representation of the area may be helpful. On my unit, the patient is required to sign a release specific to the use of cameras (separate from the admission consent) allowing us to photograph the affected area with disclaimers that the image will only be used to assist in the management of the condition (such as for consults). The patient has the right to decline and, if future photographs are to be obtained, must go through the exact same paperwork each time. The employees in my facility understand that using the photographs for any other reason than indicated above will result in very serious federal criminal charges including, but not limited to, HIPAA violation and (in ped cases) child Mediaography.
The second part of your question is tricky, but the reduction in paper charts and the increase in HIPAA-compliant E-MAR systems is cutting down on the possibility of unauthorized personnel viewing the photos. One hospital I worked at was able to track which employee accessed what information on which patient. Any unauthorized access was flagged and the compliance team got involved immediately.
Thank you, Karou. I don't think she will retaliate. I do think that she thought I would be willing to do it because of our friendship...kind of an "I'll cover your back if you cover mine." It really bothers me but sometimes I don't think she gave any thought to the potential detriment to my career and license...or hers, for that matter! I knew in my gut I was making the right decision, but sometimes situations such as this can make you question your own sanity. I appreciate you guys responding!
Please get your own malpractice insurance. And in lieu of pictures, hopefully the admission nurse did not skip over the skin care assessment? That the wound was described, measured, intervention noted and started, and a skin care plan/protocol was started?
You can take a million dated/timed pictures--but the fact remains that I would think what is documented far outweighs a picture--especially since some pictures may not be clear, can be altered...a million different things. So I would think a picture is an addition, but to be compliant I would think supporting documentation would be the key.
To Guest03/15/15, thank you for giving me your insights. I had to look up SANE but now that I know, yes, it makes sense. It is good that precautions are taken to protect this kind of evidences as well as the victims.
CamillusRN, thank you very much. I appreciate that you took the time to explain this to me (and probably to a few other people as well). Yes, it helped a lot in addressing my concerns. The more I learn about medical care in the USA, the more I realize it is different from what I know (or maybe expect?). I am not entirely convinced photographic recordings results in improvement of care but, after reading your reply, I can see some benefits to it.
liars and cheats will lie and cheat over anything. Be wary of these people. I would not back-date. It is not unreasonable for cameras to malfunction. A note in the chart could address this.
I am not entirely convinced photographic recordings results in improvement of care but, after reading your reply, I can see some benefits to it.
Sometimes a photo can be better than a nurses recorded charting for a wound. One nurse might look at a wound and describe it how she/he sees it, but another nurse looking at the same wound could describe it differently. A photo is objective and accurate. It also isn't unusual to take progressive photographs of wounds to document wound healing or changes. It's can also beneficial if say, right after the wound care is done the rounding physician wants to see the wound for him/herself. Instead of undressing the wound (which might be complicated or painful for the patient), they can instead view the photograph.
It also covers the facility. We are required at my hospital, to take pictures of all pressure ulcers on admission. Hospital acquired pressures can result in the loss of reimbursement by insurance companies. The hospital won't get reimbursed for the patients care.
On admission our patients sign a waiver to consent for photos in such cases. At other facilities I worked at, we had to get written consent because it wasn't included in their admission paperwork. It's prudent to always verbally get consent from the patient also, and educated them on the importance of the photograph/documentation.
Photographs are uploaded to the patients EMR. Only those who are caring for the patient can look at the patients chart, and even then can only look at what's necessary for them to provide care.
I do not care for minors (usually) but if we needed a picture then the parent would have to give consent. Thankfully, I haven't ever had to do that.
CamillusRN, BSN
434 Posts
Nope, not at all. Everyone involved could face charges for falsifying legal documents if such a thing were to be revealed by a whistleblower (hint, hint). Your "friend" could easily throw you under the bus if such a criminal act came to light and your name was associated with it. Good call on your part to not participate.