Is this considered falsification?

Sour Lemon · Dec 10, 2017

Hi, if a nurse edits a note to include an addendum as a correction to a note made earlier, is that considered falsification?

...only if it's false.

MommyRN89 · Dec 10, 2017

No it was the accurate data. A typo existed in the original note.

meanmaryjean, DNP, RN · Dec 10, 2017

That is not falsification- it is clarification.

MommyRN89 · Dec 10, 2017

Thank you. Does it matter if the note was titled "late entry" or not? It was just titled as an addendum and timed and dated for the date of the addendum

Crush · Dec 10, 2017

It should state late entry w/time and date. If entered after 24 hrs I believe it should also include reason such as you mentioned about it being a correction, etc.

Susie2310 · Dec 10, 2017

It should state Late Entry with the date and time.

MommyRN89 · Dec 10, 2017

There was a reason but it didn't specifically state late entry

Tenebrae, BSN, RN · Dec 10, 2017

Generally if i'm having to write an amendment/addition to a previous note i'll write something like "11/12/17 0815, following note written in retrospect for 10/12/17 am shift"

Its only falsification if its incorrect information

hawaiicarl, BSN, RN · Dec 10, 2017

So just out of curiosity .... did you write the note? Or is this a witch hunt, and you are after the person who did? Something seems off.

Julius Seizure · Dec 10, 2017

Addendum, late entry....same difference. As long as whatever is written is true and that it is clear that it was written at a different (later) time/date than whatever it is clarifying.

Meriwhen, ASN, BSN, MSN, RN · Dec 11, 2017

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?

Presuming the information being added in the addendum is correct...no, it's not falsification. I do it: sometimes the finger hits "save" before I've had a chance to fully proofread my note, so I have to go back in and put the correct info. I prefer addending as opposed to uncharting the note and then writing a whole new one.

As far as the timing, the EMR should automatically show the date/time of the addendum as well as the fact that it's an addendum, so it won't be a big secret that information was added and when. However, if you wish, you could add "Late Entry." It's not really necessary IMO, but if it makes you happy--or if it's facility policy--then do it.