Is it legal for my supervisor to ask me to alter my charting?

TheCommuter, BSN, RN · Nov 25, 2014

So, why should I go back and erase or change details about what I observed or what I did?

Because charting that is too wordy and overly detailed can potentially get the entire facility in trouble if the wrong surveyor reads it in the near future, even if it is purely factual. You never want to implicate any of your coworkers, directly or indirectly, through your documentation.

It is legal for your supervisor to ask you to alter your charting. It would be illegal if she altered your charting or forged your name. You do not have to change what you wrote, but there is a phenomenon called 'overcharting' and it hurts more than helps.

Here are my thoughts on the issue. If a colleague has potentially neglected a patient, you report your findings to your superiors. We are also mandated reporters. However, I do not believe in making things too easy for some state investigator or Joint Commission surveyor by figuratively screaming 'neglect,' 'malpractice,' or 'abuse' through overly detailed nurses notes. You report these unsubstantiated or perceived offenses, but people are innocent until proven guilty. I am paying close attention to your wording: potential neglect, not substantiated (proven) neglect.

I'd be angry if a colleague from a different shift documented a vivid narrative in the nurses notes that painted a picture of neglect allegedly committed by me when it has not been proven or substantiated, and when they do not even know the whole story. The confused patient in room 201 might be laying in a brown ring of poop because I had double my normal patient load (12 patients instead of 6) with no aides or techs to help.

Just some food for thought. I know my views are controversial, but I do not believe in throwing other nurses under the bus without knowing the full story.

ronchelednik · Nov 25, 2014

This gets touchy. We know your supervisor's supervisor wants you to sugar coat your notes. Keep this note you received from her and write a note back to her saying. "What is it that you want changed? Then suggest a meeting to be on the same page. Make a copy of how the report is now written then a copy with the changes. We know you don't want to alter your notes, it's not about that. It's about, does your notes put the hospital on liability? That's her concern so talk to her and show you are a team player. Because it's not about winning or what is right, because of that was the case their concern should be to fix the problem you brought to their attention. Remember is not about winning because I know many that won only to loose because they are out of a job.

TheCommuter, BSN, RN · Nov 25, 2014

Because it's not about winning or what is right, because if that was the case their concern should be to fix the problem you brought to their attention.

Then again, we do not know the whole story.

The staff member(s) who committed the alleged 'neglect' may or may not have been internally investigated by the managerial team. We cannot assume that nothing was done about the suspected or potential neglect. Then again, this might be a case where neglect was suspected but no proof exists that it actually happened. People are wrong about their conclusions, suspicions and assumptions all the time. But sometimes they are correct.

My point is that we do not know what happened.

LilRNonthePrairie · Nov 25, 2014

I appreciate the input! Without disclosing too much additional information, the charting from the prior shift would indicate that the client had not been adequately cared for. So, to a certain degree, those nurses didn't really try to hide the fact that they weren't meeting expectations either. However, I will say that I definitely had not previously considered how my charting might make the facility look. It's not a hospital setting, and it's not a nursing home either, and it's very small so there was no chance of having to care for extra clients than normal. At the time, I was thinking of making sure my bases were covered to protect my license. I have known people who have lost their licenses over this kind of thing, and I don't want that to be me! Also, I have seen people thrown under the bus by the facility, so I wasn't counting on anyone else having my back when it comes down to it. But, I can see how I probably did "overchart" in my effort to protect my license, and that could make the facility look less than desirable.

LilRNonthePrairie · Nov 25, 2014

As a side note, when I went back and read the charting for the next few shifts after mine, they really stepped up their care, interventions, and documentation. I really believe it was a case of the staff not realizing that the person was experiencing potentially serious complications and therefore no one intervened. But, according to the documentation, no one really tried to put in the extra effort to further assess the situation either. I can't take the blame for the client missing meds, meals, etc. on the shift before I got there. But I definitely was not going to let the client continue to decline and not intervene, and I wanted to make sure I detailed exactly what I observed and what I did so that it would be clear that I didn't just stand by and do nothing.

jadelpn, LPN, EMT-B · Nov 25, 2014

You really do not "know" that "no one put the extra effort to further assess the situation", as this is a personal judgement call as opposed to nursing judgement--

And sometimes, depending on the client, no matter what interventions are in place, the client has the right to decline. So if the client is not eating, taking meds, this is not a matter of "neglect". But it does step up interventions and family involvement on what to do next.

The only thing you can do is document your assessment, your interventions, THAT YOU SPOKE TO THE MD regarding order changes--and SENDING CLIENT OUT TO ER for further workup. IF this was not done by you after your assessment, then, it could be on you as well.

When there's any question of decline of function--I am not sure that the client staying at the facility is ever a good thing. But seems to happen a great deal.

You can only document what you are presented with, your interventions, and your response to a functional decline. Although yes, this stuff happens in a moments notice, most often it is gradual and every single nurse needs to be sure that they are modifying interventions if the current ones are not working.

And call your malpractice insurance for guidance as well.

ontheway2crna · Nov 25, 2014

There is a difference between what you write in your progress note and what you would write in a PSR. If you sounded too judgmental towards the previous nurse implying certain things, I could see where it would become unnecessary to inlcude it as part of the pt's medical record. For example, I saw a pt whose arm was so obviously infiltrated but the night RN had refused to take the pt's complaints of pain in her arm as IV KCl was infusing seriously because she was a complainer... and so her arm ballooned up 3 times the size and was very red.... he must not have turned the light on or even looked at her arm. Instead of writing in a progress note all the judgmental things you are thinking about the neglect you are seeing, just document what you see, who you contacted and what you are doing about it and try not to throw anyone under the bus, you are only perpetuating your coworkers' negative behavior by doing that as well.

classicdame, MSN, EdD · Nov 25, 2014

I would not alter anything without first talking to the safety officer in your facility. If something goes wrong, who do you think will be blamed? All the supervisor has to say is I never told her to do that.

caliotter3 · Nov 25, 2014

I would alter nothing until she is explicit with what she wants you to change and only if you agree with it. As far as altering charting, it happens often. Whether it should be changed depends on the purpose of the request. Whether you want to comply with the request is up to you. If you feel confident in what you did, leave it at that, but be prepared to be on the troublemaker list at this facility. If you do make the changes, insist on witnessing the destruction (shredding) of the original document for your own protection. Rest assured, that whatever your decision regarding this situation, you are going to be scrutinized more closely from now on for your own imperfections.

firstinfamily, RN · Nov 26, 2014

There are several words of wisdom here. My understanding of altering documentation is that there is a time limit on which to do this. For most facilities it is within 24 hours. YOu can document a new note stating it is a follow-up or addendum from note on such and such a date. YOu can only document what you did, what you assessed etc. and what you did to intervene. It will look suspicious out of order from the previous notes. Pts do have a choice to decline and if this particular pt refuses to eat and take medications that is his right. Anytime there is significant weight loss, that automatically flags as possible neglect in a facility. Your supervisor is trying to protect the facility. You need to protect your license. You cannot document what was or was not done the previous shift as you were not there. YOu can only document what assessment you saw, if meds were not signed out then that is a separate issue with the previous shift. If the pt was dirty when you found him, then sometimes that does happen, but does it happen on a regular basis?? Then that is a staffing issue. See, it is not necessarily neglect, was this particular patient targeted to be without proper care???You should only state the facts in your notes.

dream'n, BSN, RN · Nov 26, 2014

I typed up a long response and my computer turned off before I could post it So I'll make this short and sweet. Do not alter your charting. I was once involved in a State investigation (not about me) many years ago where my DON had asked myself and a few other co-workers to rewrite or alter documentation. I refused. But the FIRST question the State investigator had was if my DON had asked anyone to rewrite and/or alter documentation. Be careful.