improper charting vs backstabbing?

SharonH, RN · Mar 24, 2011

A coworker charted that a patient complained about me. She charted "Patient c/o (my name) being rude." Instead of coming to me, this coworker discussed it w/another coworker who told her she should chart what the patient said. (We all work the same shift, so I was there). I am upset that this coworker didn't come to me w/the complaint first & explain the situation. (which is that the patient was upset & verbally abusive b/c her procedure had been delayed). How do I handle this & is this type of charting legal? I feel an incident report should have been made out rather than writing complaints about another nurse in the record.

It was extremely inappropriate and irrelevant to patient care. You need to bring this up to your supervisor.

northbynorthwest · Mar 24, 2011

As usual, this is a leadership problem.

Legal medical charting is a cornerstone of quality care. If there are staff nurses, including yourself, who are not aware of how to chart, your nurse manager has a training issue. Your orientation preceptor needs better training on how to teach each of you how chart, your nursing department may lack a system-wide charting program, and ultimately your chief nursing officer is not doing one of the most important jobs she/he has, that of serious implementation of proper charting with monitoring on a quarterly basis for performance, every single year. I would suggest that you consider taking a legal charting training class for your next CEU. Even if your State does not require CEUs, I advise you to do this. Ultimately, YOU are not at fault this time. You did not create the record. But you want to make sure that your charting is always right. You cannot be responsible for the charting of another.

That said, it is never legal to chart comments by anyone on the team. A medical record is a record of what treatments and procedures were done, nursing care actually performed, and other diagnostic data. Take a copy of the note and ask to see your manager in private. Start by saying you need her help. Most NMs want to help their staff. Explain the situation by facts only. Do not show any emotion whatsoever except to be professionally concerned. Give good eye contact and remain calm in your body language. Let the NM sort through this. Learn from it and move on. Stay connected to your own care. My intuition is telling me you are not working with professional nurses. You may want to find somewhere else to work if this continues.

A word or two of advice from a nurse with 30 years experience. One of the things that is really important in nursing is teamwork. What happened to you is not good teamwork. You will learn that patients tell you things about other staff all the time, positive and negative. In the future, your best response when you hear the negative is to tell the patient that you can only be responsible for the care you give, and the patient is welcome to contact the Patient Advocate in your facility. That is what the Patient Advocate does, work through patient complaints in a formalized manner. Leave it at that and move on to your own care. Patients are vulnerable when they are sick and they say alot. Now, if you hear something from a patient that truly concerns you about their care, ie a staff member was physically abusive; a staff member forced them to do something against their patient rights, a staff member was negligent and caused harm in your opinion, you had better run to the nurse manager office. Otherwise, follow the Patient Advocate route.

I hope this helps! There is backstabbing in any job, learn to manage it - and you will over time.

:nurse: :redbeathe

j464335 · Mar 24, 2011

this is type of situation is becoming too common in our profession! i would go get a pen and paper while everything is still fresh in your mind and start documenting all of it, who worked your shift, all the contact with the pt during your shift, what the other nurses said to you, etc... document,document,document!!! i would also call my nm, immediately and make her deal with this. if it wasn't handled properly i would be sitting at my attorney's office discussing my legal options.

on a personal level.. i would not ever work another shift with either of the two nurses who came up with this brilliant idea!

northbynorthwest · Mar 24, 2011

Entries can never be removed from a chart. That is illegal. Once it is there it stays there. Followup notes can correct charting on the wrong patient, an incorrect piece of data can be noted and the correct data can then be entered, the usual laws around re-entry. This crazy note about a staff member cannot be removed. And in this case, there is no appropriate followup note. Everybody better hope this patient gets well and goes home, i.e. the chart never makes it to court.

northbynorthwest · Mar 24, 2011

Bad idea. Libel in this case would only be appropriate if the patient or staff meember was harmed from a legal standpoint. Otherwise there is no case. Plus you don't ever want to let anybody know you are thinking of suing. You will be blacklisted in a heartbeat. Lawsuits are always done in private, without anyone realizing they are coming....

Horseshoe, BSN, RN · Mar 24, 2011

Entries can never be removed from a chart. That is illegal. Once it is there it stays there. Followup notes can correct charting on the wrong patient, an incorrect piece of data can be noted and the correct data can then be entered, the usual laws around re-entry. This crazy note about a staff member cannot be removed. And in this case, there is no appropriate followup note. Everybody better hope this patient gets well and goes home, i.e. the chart never makes it to court.

That's exactly what I was thinking. Nothing can be "stricken" after the fact.

Totally inappropriate by the nurses involved. They should be sent to a remedial class on charting.

Horseshoe, BSN, RN · Mar 24, 2011

This is a classic example of libel, which is defamation by written word. You should tell the author of the note that you are consulting with an attorney about suing her for libel (even if that's not true). Bone up on libel and explain that you now have every right to sue her. You could also let your boss know what you're thinking. I'm no lawyer but I think you could probably get legal action to have it removed from the medical record since it doesn't relate to the patient's medical condition. Good luck.

If the patient really did say the OP was rude, this is in no way "libel."

It is, however, completely inappropriate in a medical record and the nurse involved should be censured and re-educated about the proper and professional way to chart in a permanent medical record, which is a legal document.

Sugarcoma, RN · Mar 24, 2011

I am also dumbfounded at why this RN felt the need to chart a pt.s complaint of you being rude. An issue like that should be taken to the manager or charge RN, maybe patient relations, but it should never be reflected in the chart.

I work on a trauma floor and we get a large population of psych patients who complain and request different nurses, techs, doctors, etc. In fact I just had this very issue today where a pt. c/o of her tech being rude and we solved it by switching techs. I never felt the need to chart this. I have taken over many pts. from coworkers and they have done the same for me when pt.s complain and We have NEVER reflected this in charting. When I do chart on these pt.s I just write "Received pt. at 11:00 a.m." and continue with my note. I would NEVER write "Received pt. at 11:00 a.m. because pt. states nurse X was rude. It is just not necessary. I agree that you need to make your manager aware of this as these two nurses need to be educated about proper charting.

Isabelle49 · Mar 24, 2011

Agree, that kind of information should never go into the patient record. After you have gone up the chain of command, try to work in another department or get out of there altogether, cause the nurse who originally wrote in the record will be lying in wait for you, like a predator. I have work with those kinds of people and I have no tolerance for them or their actions. I am considered a job hopper, but I have a damn good reason for each job that I left. I will not work in an environment where I have to keep looking over my shoulder. It's called bullying on the job and I think we will soon see laws that prohibit these acts.

Chin up · Mar 24, 2011

That's exactly what I was thinking. Nothing can be "stricken" after the fact.
Totally inappropriate by the nurses involved. They should be sent to a remedial class on charting.

Although nothing can be entirely removed, it can be crossed out (one line), dated and initialed as wrongly charted. That is stricken from the record and treated like any other incorrect entry. Yes, it can always be seen, but it is in effect, null and void. Peace!

Old.Timer · Mar 24, 2011

it has been a while and i forget all the details but, this thread reminded me of something similar.....

there was a nurse in my area who sued a physician for negatively referencing her in a patient's chart. i believe it began with the physician being an arrogant so and so about something pertaining to a specific patient. this particular nurse stood up to him.

he made sarcastic mention of the exchange in the patient's chart and referenced the nurse by name or rather an altered unflattering version of her name involving the f bomb.

she won the case and was awarded a nice little chunk of change....

noctanol · Mar 24, 2011

A coworker charted that a patient complained about me. She charted "Patient c/o (my name) being rude." Instead of coming to me, this coworker discussed it w/another coworker who told her she should chart what the patient said. (We all work the same shift, so I was there). I am upset that this coworker didn't come to me w/the complaint first & explain the situation. (which is that the patient was upset & verbally abusive b/c her procedure had been delayed). How do I handle this & is this type of charting legal? I feel an incident report should have been made out rather than writing complaints about another nurse in the record.

is there more to the story than you have portrayed, I don't see how two nurses can discuss this and then put it in a patients note. is there beef between the nurses, are they trying to get you fired???