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Help!! Problem with charting

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RN1212 RN1212 (New) New

Need opinions please.

A situation arose at my work where a nurse had left her admit note omitted. I thought I was helping her and I came in 8 hours later and put ....Late entry admit note and signed my name with todays date and a generic admit note with admit information on it. My boss said write admit summary and I forgot what he said. He agreed that a note would be better than no note and the matter was over...or so I thought.

I came back to work in 2 days and was called into the office with my manager and the director of nursing. The director said it was ...or could be considered fraudulant charting. I was suspended pending an investigation. To me this matter could have been fixed with an error or something. Does anyone know the legalities of this matter and what the employee can do?

Thanks in advance

RN1212

You wrote the admit note and you were not the nurse who admitted the patient? I don't know the legal aspects of that, but I do know it is wrong. I am sorry, but you may have to learn a lesson the hard way. NEVER chart what you did not do or see! You should have just charted your assessment when you took over the patient.

Your boss saying "a note is better than no note" is not your responsibility. It is the admitting nurse's responsibility. If you thought a nurse gave a drug to a patient but she/he did not chart it off, would you initial next to the drug? NO! Pretty much the same concept. If you didn't do it, you don't chart it.

I really do wish you luck with the outcome.

Thank you for your reply. Can you not error out a note? What if it had been a note on a wrong patient? Do you see what I mean?

Thanks again

RN1212

But was it an error or did you purposely do it? I think that is the problem. How did it come to the manager's attention? Did the admitting nurse have a problem with it? You knew you did not admit the patient but still wrote the note, so how is that an error? I am not getting on you, I just want you to look at it on the other side.

GingerSue

Has 20 years experience.

Hope it works out okay for you.

He wanted me to write a note but not call it an admit note. Why could I not error admit note out and put assessment? The admitting nurse did not have a problem with me writing it (she was off at the time). At the time when I asked him about it, he was vague about it and did not act like it was a big deal. A few days later he grabbed the chart and said we had a five minuete conversation about it and he lied and said he told me not to write it.

RN1212

this chartin stuff is making me batty

I was told that I CANNOT chart that I patient told me that she thinks she is impacted, even if I use quotes

Then I was told i cannot say a patient was cyanotic because that is a

"diagnosis" ???????

What about edema , nausea, pruritis!?!?!

Ready to throw in the towel here!

canesdukegirl, BSN, RN

Specializes in Trauma Surgery, Nursing Management. Has 14 years experience.

Only chart what you do-you know that already. I would NEVER go by what by NM tells me to do. I document what I assess-PERIOD.

Considering this is a very old thread, I wonder if the OP may fill us in on what the outcome was in this situation?

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