gardennurse

[gardennurse]

Morning everyone!! I am new to this site. I have a problem: I work with an MD and Nurse Practitioner and two other LPN's in a health clinic. The NP has taken it upon herself to change our nursing notes if the pt tells her something different than they told us in the initial interview. Just draws a line through it and inserts her notesabove ours. Isn't this very illegal? The MD is a non-confrontational type and has said she spoke to her about this but she did it again yesterday right in front of me, on another nurses chart...the nurse mangaer is aware of this and says something should be done but didn't step up. What should I do next??

[Tweety, BSN, RN]

Welcome to Allnurses.

Sounds very illegal to me. Falsification of documents is definately a no-no and what this NP is doing.

If besides bumping it up the chain of command you have confronted her directly and demanded that she stop falsifying your notes, then perhaps talking to your local state board would be the next step.

If you haven't spoken to her directly and only asked management to handle it, I would talk to her first and say you're looking into seeing what the BON has to say about the practice.

[mamason]

Yes, illegal.

[TazziRN, RN]

Very illegal. I'd be looking for another job in addition to reporting it to the BON.

[Antikigirl, ASN, RN]

Welcome Gardennurse, so great to have you!

Illegal, and not very good for assessment purposes at all! If a patient tells someone one thing, then another person another...that is diagnostic. Is that pt alert/oriented, confused, just forgot, under too much medication, needs additional education (hello NP, a nursing dx there huh?)?

The only person allowed to cross out your entries is you! One single line marked with Error and your signature (some places don't even require the word error, just your signature...but I put error just in case).

When I have come up with items different then nurses before me, I simply state that at '___ (time, date), the patient said ____________, which differs than the notation on _________ told to _________. That way a descripancy is noted in statements and can be investigated PRN.

And on a personal note...that would make me sooooooo angry! Don't mess with my notes...I am a professional and what I say is professional and required of me...NO ONE should be messing with that! Isn't that why we line out and sign at the end of our notes...so no one can add on under our names? GRRRRRRRRRRRRR!!!!!!!!