Documenting for someone else

Nurses General Nursing

Published

Sigh...I'm being asked by my DON to document immunizations given by MAs who are no longer with our company and who failed to document and submit them. I am completly uncomfortable with this. I was told today that if I don't know if it was given I need to look at the doctors note to determine if it was given, if I'm still not satisfied I need to contact the parents of the patients and ask if the patient received the vaccinations. She told me all I have to do is document that it was given and also document what ever MA I presume gave it, gave it. The rational is that the patient needs to have a correct MR so that they don't end up having to get the same immunization. The problem is I can't guarentee what MA actually gave the vaccination as there is no documentation to tell me-I can tell who roomed the patient but I can't tell if another MA jumped in and gave the immunization and I can't be 100% sure the immunization was actually given in the first place. A majority of the patients will have a form scanned in the chart with an order/document that states that at that visit with those imz ordered they are now up to date on their IMZs-but again there is no signature by anyone that actually would be giving the vaccines, only the doctors signature at the bottom that should signafy that they ordered those vaccines and they were given. I can contact the parents but so many parents can't tell you how many immunizations their child got on any given day (and I'm looking at a 5 month time span) let alone what they were.

Does anyone have any advice on what to do or resources that I can go to?

Thank you!

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Specializes in Emergency Nursing.

Every time I've given an immunization I have had to log the expiration date, lot number, and manufacturer. There's a lot of documenting to go along with them. I would not be comfortable assuming anything and placing that assumption into a legal chart. Good luck reasoning with your DON!

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My understanding is that federal law requires documentation of:

Date vaccine given

Date of publication of the Vaccine Information Statement (VIS)

Date the VIS was given to the patient (or parent/legal guardian)

Manufacturer and lot number of vaccine

Name, title, and clinic address (location where immunization information will

be stored) of the individual who administered the vaccine

If there is no way for you to recreate that information, then you cannot document the vaccinations.

So sorry, what a yucky position to be put in.

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Because we do daily inventory I can determine the lot and exp that was available that day. The things I can't determine for a fact is the person that gave the vaccine and if the vaccine was given for sure. My DON seems to be set that I will be doing this. Her email to me pretty much stated that I needed to problem solve and get it figured out and get it done.

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Specializes in Family Nurse Practitioner.

She is passing the buck of illegal activity to you. The answer is "No, I cannot falsify documentation." Whether you agree or refuse this situation can be used against you in the future as a reason to fire you. Get a new job ASAP.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.

Yes, she's trying to get you to do the illegal thing. That way, if it is discovered, she can conveniently point a finger of blame at you. It might be hard to find a new job, but there is no finding a new license.

This sounds like a very poorly managed workplace. MAs giving vaccinations without any documentation? Trying to reconstruct it after the fact? You might want to run this past your BON on your way out the door. Good luck!

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Tell her if she feels that's right and legal, to do it herself. Bet she won't.

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Specializes in ER, TRAUMA, MED-SURG.
Yes, she's trying to get you to do the illegal thing. That way, if it is discovered, she can conveniently point a finger of blame at you. It might be hard to find a new job, but there is no finding a new license.

This sounds like a very poorly managed workplace. MAs giving vaccinations without any documentation? Trying to reconstruct it after the fact? You might want to run this past your BON on your way out the door. Good luck!

This! That was my thought also.

Anne, RNC

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Specializes in LTC Rehab Med/Surg.

I do not sign off on things I didn't do, unless I've witnessed them myself.

It's a personal policy. A line I won't cross.

What you're being asked to do is all kinds of illegal.

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I would hire an attorney

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Because we do daily inventory I can determine the lot and exp that was available that day. The things I can't determine for a fact is the person that gave the vaccine and if the vaccine was given for sure. My DON seems to be set that I will be doing this. Her email to me pretty much stated that I needed to problem solve and get it figured out and get it done.

Oh, and save that email!!!

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NO WAY!!!

I agree.....save her e-mail as proof of what you are being asked to (illegally) do. Maybe tell her you would feel more comfortable if you first called your BON and ran it by them to make sure it's okay :sneaky:

Let us know how you handled this situation and good luck! That's a tough spot to be in.

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