advice needed

  1. My DON is having me audit charts prior to joint commission coming. She told me when she finds information is missing or incorrect she "just fixes it". These are closed charts and she told me if it didn't sit well with me to leave her a note and she would go back and "fix" the charts I audit. Oh help!
    I don't even want to do the audits now. Should this bother me or am I being silly? Shouldn't I report this somewhere? Has anyone been in this situation before?
  2. Visit RehabRNjc profile page

    About RehabRNjc

    Joined: May '12; Posts: 16; Likes: 61


  3. by   1hotnurse08
    I used to audit charts on a daily basis. When there was a correction that needed to be made we usually emailed or contacted the nurse/ nurse manager or any other clinician that was associated with the chart. I never altered anyone's records. I understand your concern. If you don't feel comfortable then just let the DON know that you're uncomfortable with flagging the charts. I just wouldn't do anything that I feel is uncomfortable, not within my scope or may affect or compromise my license.
  4. by   Blue Roses
    I would say if you feel uncomfortable then don't do it. Better safe than sorry. If your boss tries to bully you into doing something you're not totally comfortable with then that boss isn't a very good boss.
  5. by   Laboratorian
    Just fixing it is not proper corrective action & defeats the purpose of performing an audit.
  6. by   RehabRNjc
    She told us to just make up a weight, if a weight was missing. "Just look at what the patient weighed the day before and the day after and put something in, you know, common sense."

    I can't. I won't.

    I believe there is a line between right and wrong and the more times you cross that line, the easier it will be to cross it again. On a small scale, no body is being harmed by this illegal activity, but on a larger scale, we will pass joint commission by lying and in the long run this could maybe cause harm. I don't' know.

    I don't directly report to her, so I'm not worried about her directly disciplining me. I am uncomfortable with performing the audits knowing she is going to go behind me and alter the medical records. I feel like I should tell someone for several reasons: 1) When she was instructing the two of us to alter the medical records, we were in an area where we could (and probably were) overheard by the Director of Medical Records. I suspect if he overheard her, he will report her and us, and I could be accused and it would be hard to prove that I didn't alter the records (the other nurse altered some of those records last night). 2) What else is she lying about and covering up? We have had a few suspicious deaths where the nurses notes from that shift disappeared and re-appeared written differently. (I end up reading the nurse's notes as part of my cushy RN desk job.) 3) I really hate knowing this, I wish she hadn't told me what she's doing because I have a big mouth and it's bound to come out someday anyway.

    Who would I even talk to about this? Someone who is instructing others to make up vitals, pain assessments, ect, is probably so far gone that confronting her probably would only make her angry. I can't stand making people angry.

    I can't stand moral dilemmas.
  7. by   twinmommy+2
    If you have suspicion, then you can call JCAHO anonomously on

    If you feel conflicted this might be a good way to more permenently resolve the issue.
  8. by   cmbuckley
    Run away you are going to be falsifying MEDICAL RECORDS that could one day end up in a Court of Law. I`m sure that`s a Felony and it`s definetly Morally Wrong.
  9. by   mclennan
    I used to audit charts to prep for surveys. I was asked, also, to make "corrections" exactly in the fashion you are being asked. I SAID NO. FLAT OUT. ABSOLUTELY NOT!

    I agreed to flag charts that lacked information and that was it. Any action beyond that was up to managers and whoever signed off on incomplete documentation. I let them know, DIRECTLY and UNAPOLOGETICALLY, that if I suspected or witnessed any tampering of, disposing of, shredding of or unethically altering of past documentation, that I had no problem letting the Joint Commission know. I also reminded them of whistleblower's laws. I was there to audit charts and identify patterns of incomplete documentation, NOT to make friends. My professional integrity and an intact license was more important to me than supporting this employer's dishonesty.

    Don't do this! Contact the Joint Commission with your concerns, they WILL protect your identity and WILL follow up with an investigation.
  10. by   RehabRNjc
    This has become an ugly mess. The other nurse she told to do this, did, and put a big sign up that said "all discrepencies have been resolved."

    I had just not done the audits and when DON approached me and asked how the audits went, I told DON "I had trouble finding the charts in medical records and they didn't get done, sorry."

    DON flipped out on me about how DON has so much work to do and, to DON's credit, DON walked into a mess Monday. I went to the person I report to and explained the situation and was told to "just do the audits and flag the parts that need to be fixed." REALLY?? Everybody knows this happens and I'm susposed to enable it? I went and did the stupid audits, but didn't flag anything. Then my dumb self went to HR and informed them that when our company is caught committing fraud, I wanted it to be noted that I refused to do it.

    A few hours later I was stuck in a meeting with DON, other nurse, and HR. Ambush perhaps? It was very ugly as the other nurse had already done the audits and cheated and so she said that DON had not told her to do anything she was not comfortable with. DON told me I was dangerous and was trying to destroy a 40 year career because DON occasionally wrote a couple weights in closed charts. She said she didn't want me near her charts (GOOD!), but went on to berate me in so many ways. It stunk. (I'm so proud of myself, I didn't cry until half-way home.)

    Now I feel like crap, I'm on AN instead of going to work, I'm going to be late, but I have no desire to deal with anyone. Aparently, this is how our company opperates, but I doubt they will try to involve me in any of their nonsense again.

    One more thing bothers me, I had audited the charts that the other nurse re-audited and my audits are missing, so I have no way to prove that I'm not just some crazy person. I'm not crazy (well not throw cats at passerby's crazy), but I thought DON was a mentor to me and I would have done anything for DON, almost. I have NO respect for DON anymore and I have a broken heart.

    I wish I was a billionaire so I could just quit and put that whole mess behind me.
  11. by   nurseprnRN
    Yep, the handwriting's on the wall. If you don't quit they'll find some way to screw you anyway. Put in your notice, put it all in writing to the auditing agency and the board of nursing (in case they try), and thank your lucky stars you're out of there.