Help! Documentation question

i think it would be highly dependent on what exactly was written and how it was worded.

i think we need a bit more information before we can comment. thanks !

praiser :heartbeat

You are permitted to chart after the fact. All you have to do is go back to the chart, draw a single line through it, sign and date, also say 'incorrect' (try to avoid the word 'error'). Then you write: 'x/x/09 time ammendment to (whatever date and time the crossed out entry was) entry: here you would write the corrected entry.

This is totally legal and used often, since we are only human and make mistakes. A lawyer will hang you if you lie or try to cover up something. The single line makes the orginal entry still readable (not trying to hide anything) and the corrected entry will show that you were just having a bad day, realized it and corrected your mistaken way of charting.

I figured you all might need more info. I was trying to be generic, but I guess I will go ahead and disclose the details...

An RN was working in a doctor's office in their coumadin clinic and the patient had an off the chart INR result. It was known by a few of the other nurses there that this patient's family member (also an RN) has a history of occassionally adjusting the patient's doses, despite how he was advised at the coumadin clinic. The patient and especially the family member always wanted the INR to be X (i.e. an exact number with very little variance). The particular nurse in question added a narrative about the results/visit that day basically saying reiterating this historical info. (med. adjustments), but messed up by saying something to the effect of how the family member "often overreacts when the patient's INR is not exactly X...", I guess in trying to further support the notion that the patient's crazy INR was not because of any advice given at the coumadin clinic.

Please ask me more questions if anything is unclear.

Thanks.

Sorry, I forgot to add that it was computerized charting.

I'm not sure I would change anything,...especially if she quoted anything said,......she covered her butt,...it wasn't her or the clinic that adjusted meds,...our computerized charting does allow for late entry and errors in charting (ie wrong chart) so it could probably still be fixed if she really thinks it's necessary.

I don't think that was subjective at all. She just stated the facts.

Now, if she said something along the lines of "pt's family is a pain in the *** about the INR and need to take a chill-pill" then that would be bad.

i agree with pepper - that sounds pretty factual to me. Remember that we are told to document everything. This can include happenings with family members and their reactions. Documenting that a family member overreacted, maybe in the future put more so in terms of exactly what their reaction was - i suppose that the overreacted part could be considered subjective - could provide a clue down the road - especially in med dose tampering is suspected.

Yes I would say in the future to avoid using terms like "over-reacted", but I would not try to correct the charting. It may be worded poorly but it did lay out the situation.