Is this considered "altering" of a chart?

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If you discover a charting error (that is months old) made by another nurse (she charted that a prescription was ordered and it was not) and you place a line through it, initial and write "see new entry" and then clarify what really happened (that the client did not receive that Rx from the pharmacy etc.) and sign it; is this considered ALTERING?

I know us old timers were taught the "line-out" rule, write ERROR/ME/CORRECTION etc. and initial and I felt that applied to this situation.

No, we do not have a written P&P on charting techniques........

Thanks!

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Specializes in OB.

You can correct your OWN charting with a late entry. You do not correct someone else's charting. If you find what you consider to be an error in someone else's charting bring it to their attention and let them make the correction.

If anyone took it upon themselves to "correct" my charting without bringing it to me I'd be writing up a complaint on them!

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Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

OK, first you never chart for someone else.....therefore you cannot correct the charting.

Second you definitely need a policy on charting.

Third if the patient/family or doctor made an issue of it you make an occurrence report saying ONLY what you know and can prove is the truth. No names and preferably no he sad/ she said.

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Specializes in cardiac/critical care/ informatics.

Yes it is altering a chart, You NEVER EVER correct someone else's charting. I agree with the suggestions from the op's

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Specializes in LTC, Memory loss, PDN.

Something similar happened to me. Another nurse modified (word choice intentional) one of my entries in a patient's chart. When my boss asked me to make a late entry "...to clarify things", I explained that it was someone else's baby now and that I wouldn't touch it with a ten foot pole.

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