Is this considered falsification?

[MommyRN89]

Hi, if a nurse edits a note to include an addendum as a correction to a note made earlier, is that considered falsification? The original note was not deleted but an addendum was added. The original note contained a set of vitals. The addendum contained a correction to the vitals. Also, the addendum was made 48 hours later. Would this be an issue?

[mmc51264, BSN, MSN, RN]

I addend notes to add information. I will do a late entry if it something that I forgot to chart. The notes and revisions are all time stamped so that is already there. I don't think I have ever done one >24 hours. I can access our intranet from home and sometimes I ad things when I get home. If it is something urgent that night shift needs to know, I always call to tell both care nurse and charge nurse and THEN I document that I called as well.

And like others have said, as long as the information is not false, it is not falsification.

[djh123]

I did one tonight. It wasn't technically a 'late entry', but more of an addendum. I started a change of condition, and described what was going on with the resident, but forgot to mention another new thing, so I then entered a nursing note and made it clear that it was an additional note that i'd meant to enter with the original change of condition.

[Guest219794]

Falsification would refer to things that are false- hence the term.

If this was truly a concern, then nothing could ever be corrected. Respirations would have to remain at 112 and a heart rate of 16.

As far as actually typing the words "late entry" into the note- I would say that is a hold over from paper charting. It is clearly a late entry.

[bsyrn, ASN, RN]

It is only considered falsification if the information is false.

[Castiela]

If I make changes to my electronic charting, I usually link a note saying why I made the changes...