falsifying medical records - page 2

I am so angry right now, I don't know where to start. Anyway here it goes. I work in the emergency department of a major trauma center. Last week while checking an admission chart for... Read More

  1. by   aronel
    I went to the er recently with bronchitis and chest pain. The doctor talked to me but did not examine me...and I sat in a chair the entire time...the nurse did listen to my lungs. When I got a copy of my medical records I saw that they charted negative findings of a complete physical including that my adbomen was none tender and without rebound. They never touched me except for the nurse listening to my lungs. I worked in an ER for many years and wondered at the time why they didn't examine me a little more throughly.
    I am just amazed and I am very upset and just don't know what to do. Should I report this to the medical board, nursing board, hositial association? Should I call the hospital and ask to talk to someone about this? What does one do in this case?
  2. by   Batman25
    Good for you for going to Risk Management. You also however need to put this incident in writing and be sure to keep a copy. I'd even send it certified mail return receipt or by email so if anything comes up down the line you have proof others were aware. They can't sweep it under the rug if there is written documentation on it.

    Don't let this go. What she is doing is illegal in so many ways and puts you and the facility at great liability. Make sure to emphasize the latter. If someone sues they will win oddles because of this issue. I prob would have literally had a cow on the spot had I seen this was going on. Keep us posted.
  3. by   mykrosphere
    i dont even know how to reply, except the new job thing.....yeah.....do that!

    i have been encountered with this a couple of times where i was just told to "chart this" or "chart that" and i could not do it. i didnt lose my job over it, but the charge sure was not happy. i do not work there anymore.

    just a couple days ago i found an error where a doc charted in a pts chart that was not even his patient and wrote an insulin order and progress note....
    it was obvious who he meant to chart on i guess, the room next to the one he did, and i heard from the oncoming nurse that i should just take the progress note out of the chart and put it in the right chart and put a new sticker on.....

    im sorry but IM NOT DOING THAT!
    that is altering a record and i will not be responsible for any doctors mess up.
    i passed it on to the charge and hopefully they can take care of this.
    there was no harm done thank god, but what if there was?
    it would have been nursings fault....

    just take care of you and what you are responsible for.
    i couldnt imagine taking the fall for someone elses screw up at this point in my life.
    we have enough to worry about!
  4. by   K+MgSO4
    This thread is 10 years old!
  5. by   ShellyRn1117
    Quote from K+MgSO4
    This thread is 10 years old!
    Lmbo it is ten years old, but a lesson to be learned today...nothing changes. We still face these issues darn near every day. I needed a laugh today!