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Discussion

Falsifying documentation

Hi,

A patient of mine whom has multiple foot wounds whom I see for wound dressings made a complaint to me that one of the previous nurses had attended 2 out of the 3 wounds on his foot only. The nurse was bandaging up his foot and when the patient realised that she had missed the other wound, pointed it out to her. She continued to bandage up the foot and did not attempt to dress the remaining wound. The nurse then documented that she had attended all of the dressings and left.

When I went in for the next visit, the patient advised me of this, I took the bandaging off and there was indeed no dressing on the wound in question.

Is this considered falsification of documentation and what would the consequences be?

Thanks

Featured Replies

The issue isn't with the documentation, but with the fact that the patient pointed out a mistake and the nurse didn't correct it. Sure the documentation is false, but the nurse's actions are of more concern to me. I'd report it to your supervisor and let them deal with it.

The issue isn't with the documentation, but with the fact that the patient pointed out a mistake and the nurse didn't correct it. Sure the documentation is false, but the nurse's actions are of more concern to me. I'd report it to your supervisor and let them deal with it.

Again, we don't know that the documentation was false or that a mistake was made. If patient has issue, patient can report. If patient wants a form and you have the form, give it to them. Patients know how to complain more than how to comply with treatment plan. Also, from experience, there are many patients that cannot tell you the name of the lifesaving medication they take (2 white ones), so it is not far-fetched that the family may not have noticed the dressing or are mistaken. Our reaction to patient complaint often determines the outcome. Acknowledge the complaint. If it was mentioned casually, leave it alone. If they are concerned or upset, follow protocol. I always notify person involved, because often there is a very simple explanation, and everyone is satisfied.

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