Is it legal to rewrite nursing notes 3 months later?

CC Girl · May 12, 2011

I would just make sure you make note of it being a "late entry rewrite" with the current day's date. If they are somehow trying to cover something up it's not good. Nurses notes are legal medical documents. Cover YOUR butt! :)

BabyLady, BSN, RN · May 12, 2011

I just received an email from the manager of my home health care agency. She discussed how my notes were audited and because i scribbled out a word and wrote "omit" on top of it that i was going to have to rewrite the entire note. There are 16 dates (over a length of 3 months) that I had done this on (because i thought it was ok to do) and the notes are atleast a full page if not 2 or 3 pages. Am i legally allowed to re write an ENTIRE note 3 months later. I understand now that "omit" on top of the scribbles does not cut it and we are only allowed to put a line through our error, but to re write 16 notes because of one word scribbled out on the notes seems a bit much. I suggested initialing the scribble but she said that wont cut it. HELP!!!

Once something is in the notes, you are not permitted to omit it...even if it is wrong or the wrong patient. You can add as late entry, but you cannot toss out what is already there.

You also, cannot "scribble" out words that you write incorrectly. The proper and legal way to correct these errors is to draw one line through the error (so that the original writing can still be read) and your initials on top of it..that demonstrates the error.

This exact situation is actually an NCLEX question now.

allnurses Guide · May 12, 2011

How would you go about correcting that error only? You can't unscribble the word, so any targeted correction wouldn't tell the auditors what you scribbled out or why you felt the need to omit it. They really just can't take your word for it and decide the note is conforming to standards for documentation.

Most likely you will need to do them all over. We had an issue with the MAR on one of our patients. Our MARs are empty graph sheets, so the re-do involved rewriting all their meds, dose time ending - the whole enchilada. It was awful.

But our DON wanted us to do it, so we did. I'm wondering as well why you didn't know how to correct an error, that tends to rank right up there with the 7 rights and never ass-u-me :) so our instructors would bonk us with nerf bats for that.

(not really)

merlee · May 12, 2011

Your original notes must stay in the chart. Period.

And are you saying you were never taught how to correct an error (the one line through it issue) in your notes? And you did this on multiple occassions? Wow. This is a very sticky situation. I realize that in home health each visit stands alone, but it is not ethical to simply make a prettier copy to avoid getting hit by one or more of the overseeing agencies.

Part of the issue here is how often someone is doing internal audits of the charts. The answer here is obvious - not often enough. Notes should be audited before they are posted to the charts. Your administration is remiss here, and they are now trying to cover for their own inadequacies.

Whether or not your manager wants you to 'rewrite' notes, the originals must remain with the chart.

Whispera, MSN, RN · May 12, 2011

I wonder if a written message, written today as a late entry/additional note, that states your misunderstand of how to omit parts of a note, and the situation, would cover it? It seems a big waste of time to re-write things that legally must remain in the chart anyway.

AnnieOaklyRN, BSN, RN, EMT-P · May 12, 2011

You need to write an addendum and keep the current notes. Do not write them all over this would look suspicious in a court room!

Happy

BeenThereDoneThat74, MSN, RN · May 12, 2011

I understand now that "omit" on top of the scribbles does not cut it and we are only allowed to put a line through our error, but to re write 16 notes because of one word scribbled out on the notes seems a bit much. I suggested initialing the scribble but she said that wont cut it.

Okay, let's lay off on what should she have done, she gets it.

I think the word "omit" is what seems awkward. To write omit suggests (IMO) that you want the word(s) out of there. The word "error" suggests a mistake, maybe a typo or gramatical error. My thought is, as long as you can see through the "errored" word, it shows you're not trying to hide anything.

I would NOT rewrite the note 3 months later. What would you write? Has anything changed? You accurately (I am assuming) depicted what went on at that time with this patient. I am wondering if there is anything going on with this patient, that has triggered them to be looking at your notes 3 months later.

allnurses Guide · May 12, 2011

I think the OP will probably have to insist they keep both notes in the chart. At least she didn't ask you to put things in the note that you didn't do. I've seen that happen a few times.

It isn't unusual in home health for someone to be asked to rewrite their notes, and toss the old one. Typical reasons -- drawings of little clocks, coffee stains or using blue ink instead of black.

It's also not unusual for charts to be reviewed 3 months after they are written. Yes, they are supposed to be reviewed soon after they come in, but very often they're not. Many agencies have the note do double duty as a time sheet. If there's something weird about the time sheet, they ask people to rewrite them then, too.

One of the biggest issues we face is the haphazard communication lines between the doctors, the nurses and the office.

Emergency RN · May 12, 2011

In terms of my opinion, I would be disinclined to change anything and would tell the employer so. I would apologize for the charting error and let the chips fall where they may. My rationale is, losing a job is still better than losing a license.

That said, the OP's question instantly recalled something really humorous that had happened when I was in nursing school. We had just been subjected to a long lecture about the legal responsibilities of nurses and how each of our notes may one day be a part of a court record, and what the proper procedure was to legally adjudicate charting errors (the aforementioned single line strike out with annotated initials).

So of course, the very next day, we were doing our psych clinical rotation and we all sat there looking at a Certified Social Worker on the locked unit, using the commercial paper correction product "White Out" to paint out entire passages of notes and then rewrite over them. The real kicker to this, was the institution we were doing clinical in, just so happened to use green tinted paper for their progress notes. This woman somehow had obtained the White Out product in a green colored formulation, allowing her to perfectly match the exact same green color of the paper.

All of us silently looked on in dumbfounded amazement at such a glaring example of how not to do it, stunned at the lengths that some people would go to, in order to cover up their errors.

UPSBossman · May 12, 2011

as someone who works in risk management, here's my $0.02

-disclaimer- laws vary by state, so what i say may not apply to you.

per my understanding, once something is charted, it can not be changed. i agree with the above statements that you should write an addendum and add it to the chart, but do not remove anything. these are legal documents and can not be removed. on any notes/addendums/changes that you make document the date of the changes so it is clear this was not part of the original chart. if your employer insists that you re-chart everything, ask them to show you how this is legal, as you will be changing part of a permanent legal document. put a statement at the bottom of the chart saying that your boss has informed you that the re-write is legal and that the chart was recreated at their insistence. if its at all "gray area" your boss won't want to sign anything like that, and that should be a flag.

or, for the best answer you can get, contact a lawyer who practices healthcare law and ask them if its legal. most hospitals probably have one on hand (risk manager or similar position.)

ljeanmarielouise · May 13, 2011

Rewriting any notes is tampering with the medical record and could land you in serious trouble if there is ever any type of legal question.