Correcting Another Nurse's Charting Error??

Nurses General Nursing

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So I started a new job and I'm currently in orientation. Today we were introduced to the hospital's computer system for charting and medication administration. The instructor which was also a nurse began talking to us about documenting in the computerized MAR. Then she started talking about a scenario about if we see that another nurse has charted the wrong dose or wrong glucose level or the wrong number of tablets given or if they even forgot to document that they gave a med that you can check with the nurse to see if they gave it and if they gave it correctly then you can go in under their time of caring for that patient and basically chart that it was given and document in the notes that the other nurse has stated that she did in fact give the med. First, why have a computer system that doesn't recognize this immediately when you are in the process of giving the medication??? Second, I don't know about you but I felt that what she is saying is that I can basically change someone elses documentation which was/is a no-no where I used to work and when I was in school. And how should I even know/trust that when I ask this nurse if she gave it that what she said is true. I questioned her about that and she as well as other nurses in the room were saying how nurses have to have each other's back and we should trust that what the nurse said was true and sometimes we make mistakes and we should help each other out. I understand that but isn't changing someone elses documentation illegal, even if it was wrong??? Help me out people!

Specializes in LTC.

we just switched to eMARs in the facility where I am at. We have had this situation occur several times. The first step is to help prevent it from happening. My supervisor suggested to me that when we get/give report that we check the off going nurse's eMAR just to validate that all meds have been given and charted as such. This has helped greatly.

And in some cases we do have to chart, such as if our CNA does not do their charting we have 3 options: 1) get information and chart is as info obtained from CNA per telephone interview 2) call CNA in to do it themselves 3) REQUIRED if 1 or 2 is not possible: an interview of care provided to resident, and a head to toe assessment ....Again the best policy is prevention....We check our CNAs and off going nurse before they leave...Just having to do a few of those head to toe assessments will make you think to look and see if it was done!

Hope this helps

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Specializes in Trauma Surgery, Nursing Management.
I'll give you an example. We had an urgent case where a patient was getting multiple medications at a rapid rate. Lots of nurses and docs involved at the same time. After the dust had settled I was going over the event and saw that solumedral was not charted by a nurse who I knew had given it. The nurse was long gone and not coming back for days. I called him at home, he confirmed that he indeed gave it. I charted that Nurse XXX had given the med. We have computerized charting. I charted under my name, not under his password and ID, so it was clear that I was charting for another nurse. Our system is built to allow for this.

I have done this very rarely, so when I do I always write a quick progress note explaining (just as I did above), so that if the chart is reviewed anyone can see the chain of events that took place. It is important that the medication be charted for their future care. If I don't know a medication was really given, it may be given again too soon. Or it may not be given again because the doc didn't realize it was really given and indeed the drug that turned things around. It is dangerous not to chart.

Charting by proxy is an acceptable thing to do when the circumstances warrant. I would never chart a med I didn't give in a way that made it look like I gave it. I recommend adding a progress note that makes it crystal clear the circumstances.

If you put what is best for the patient first, remember to document what was done and why, I think you will be just fine.

In that situation, then you KNOW the med was given. I would have done the same thing you did, because I was there when the med was administered...kind of like documenting meds during a code.

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Specializes in Medical/ Neuro/ Telemetry.

Yeah, I'm not ok with covering for someone else mistake!!!!

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You're not covering up their mistake. You're charting in such a way that the patient will be protected. There's no hiding what happened and nothing shady in what you're doing. I would much rather do this than take a chance that someone on the next shift (two shifts after the lapse) would end up giving an extra dose or exceed the proper amount of acetaminophen in a 24 hr period or something similar because I didn't clarify the discrepancy.

One mistake was already made. Better for all concerned that it not turn into more.

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Specializes in Intermediate care.

I don't necessarily have a problem with this given i will NOT chart i gave it if another nurse gave it.

What i do is call the RN that gave it and chart it. We have different options we can chose when we are giving a med such as "Given" or "Held" or "Given by other" (there is many options). I chose "Given by other" then it prompts you to say who gave it. Your name WILL be on the MAR at the time it was given, but it is only on the MAR stating you are the RN that talked to that RN.

If that makes sense? So their name shows up that they gave it, and your name will show up that you spoke to them. Then you chart the time you spoke to them about it.

^That i have no problem doing, as long as they aren't lying and did indeed give the medication. You can also go back to pyxis and check to see if it was pulled from pyxis. I get hesitant doing this with narcotics, but if it is like a metoprolol or a calcium, why would anyone want to take those?

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:nono::bugeyes::redlight::smackingf

I have read this thread for the last day or so. I am just a little worried about how some of the responses are promoting the idea it is okay to change an entry in a chart(specifically changing an entry documenting the performance of a nursing action that was performed by another nurse). First, the EMR's are relatively new and are still evolving. That being said the discussion about how to change a chart has not significantly changed for years. Look back on what you were taught in school, add in your experience at work, and don't change any chart without seriously considering what you are documenting. The typical administration response is that the change can be accomplished without any problem associated with the person changing the chart. Alarms should instantly go off in your head. I respect and protect my license daily, and will not risk it being taken away for anything. If (knock on wood) this chart would be involved in litigation for any reason don't think a lawyer will not take advantage of the situation.

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The woman giving that advice is so wrong it's not funny, do NOT listen to her! If you find a mistake the proper thing to do is call the person who made the error and let them be the ones to correct it.

There isn't a lawyer out there who couldn't completely shred your professionalism, knowledge and ethics if they ever found out you did that!

If that woman thinks it's such a good idea, let her do it herself, but you be the one to continue to do things correctly.

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Perhaps we can look at this another way.

Let's say you are the patient. Among many other problems you are in a hypertensive crisis and given labetalol by one of the nurses. After things settle down your nurse (who was being helped by other nurses, doctors and resp therapists) notices the labetalol was not charted. What would you want him to do?

A. Forget about it b/c it's not his problem. People should do their job right the first time.

B. Say, "oh she can chart it in 3 days when she comes back".

C. Find a way to reflect what actually happened so that further treatment can be based on your response to the medication that was given.

Each system is different. Some make the process easier than others. For the optimal treatment and safety of our patients it is our responsibility to find a way to reflect what treatment the patient received.

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Perhaps we can look at this another way.

Let's say you are the patient. Among many other problems you are in a hypertensive crisis and given labetalol by one of the nurses. After things settle down your nurse (who was being helped by other nurses, doctors and resp therapists) notices the labetalol was not charted. What would you want him to do?

A. Forget about it b/c it's not his problem. People should do their job right the first time.

B. Say, "oh she can chart it in 3 days when she comes back".

C. Find a way to reflect what actually happened so that further treatment can be based on your response to the medication that was given.

Each system is different. Some make the process easier than others. For the optimal treatment and safety of our patients it is our responsibility to find a way to reflect what treatment the patient received.

Thanks! That makes a lot more sense to me. I think people are way too caught up with the restrictions of their particular system. And also the cover your a** factor. I always try to think of what is best for my patient and then think of how to make it happen with the computer system I have ... that way the system we have doesn't dictate my patient care. :yeah:

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:nono::bugeyes::redlight::smackingf

I have read this thread for the last day or so. I am just a little worried about how some of the responses are promoting the idea it is okay to change an entry in a chart(specifically changing an entry documenting the performance of a nursing action that was performed by another nurse). First, the EMR's are relatively new and are still evolving. That being said the discussion about how to change a chart has not significantly changed for years. Look back on what you were taught in school, add in your experience at work, and don't change any chart without seriously considering what you are documenting. The typical administration response is that the change can be accomplished without any problem associated with the person changing the chart. Alarms should instantly go off in your head. I respect and protect my license daily, and will not risk it being taken away for anything. If (knock on wood) this chart would be involved in litigation for any reason don't think a lawyer will not take advantage of the situation.

It is NOT okay to change someone else's charting. That isn't what most of us are talking about. We are saying that if we knew that a med had not been charted but the previous nurse said it had been given, we would chart under our own names, and make an addendum to the chart stating what the other nurse said she gave and when she said she gave it. We would do this for the patient's protection. That's an important consideration.

We would not be falsifying anything. We would not be hiding anything. We would not be charting under the other nurse's name or making it seem like she was doing the charting. We would merely be documenting what was told to us (especially if there were corroborating evidence) so that the patient would be protected from an overdose, doses given too close together, or unnecessary doses given.

Seems like some folks can't let go of the idea that something underhanded or illegal is going on here when it really isn't.

There is no element of deception. We're not talking about covering anything up. The other nurse's lapse is there for all to see. But so is the crucial information needed to keep the patient safe. To me, that trumps everything else.

If you still don't think this is right, what would you do instead?

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Specializes in Critical Care.

I'm not really following the logic of many posters here. Correcting charting is not falsifying charting, in fact they're essentially opposite of each other. Falsifying charting is entering data you know to be incorrect. If there is data in the chart that you know to be incorrect and you fail to address it that's essentially falsifying charting even though you didn't originally chart it, you were still aware of the incorrect charting and allowed it remain in the chart without attempting to address it. That's what could put your license at risk, not correcting false charting.

I also don't get the "it's not my problem" argument, so who's problem is it? When it comes down to it, it's essentially the patient's problem making seem sort of negligent to make no attempt to address it.

Correcting charting is not only allowed, it's expected, which is why every EMR I've seen is designed to facilitate corrections, even paper charting has a legal defined to correct your or another Nurse's charting, which makes the "I'm not risking my license" argument seem pretty ridiculous.

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