Recently, I had to write up an incident report, and wrote a progress note in great detail about the events that occurred. My colleague and I were concerned that this client had possibly been neglected on the previous shift, and we did all that we could to intervene.
Yesterday when I got to work, I had a note from my supervisor's supervisor, asking me to go back and "re-write" certain parts of my progress note about the incident. She went on to say that it is "nothing bad", but that certain details "leave a bad impression".
I went back and read what I had charted, and it is all factual. I did not include my opinion about anything. I do not feel comfortable going back and altering my charting, especially when it is because I'm being asked to change it to make it sound different. Not to sound cliche, but it is what it is. When there's an issue of potential neglect, it's usually not going to sound pretty. So, why should I go back and erase or change details about what I observed or what I did?
She did not specify what she wanted me to add in or edit out, so I am still unclear on what exactly she wants me to re-write. Can anyone tell me if it's even legal for her to ask me to re-write my charting to leave a better impression? From the night I walked into this situation at my job, I had a feeling it could be looked into further, so I charted very detailed. Would it look bad on my part to go back and change something? I should also add, we still use paper charting so I don't even know how I would go about editing hand written charting anyway.
