Is this legal?

Nurses General Nursing


Hello, I would appreciate some feedback about a situation I am facing. I'm an LPN, I used to work for a pediatric home health agency, I left the case I was on about 3 months ago. Recently I received a call from the new case manager for my patient stating that I need to go to the office and sign MARS from three months before I quit because three months of MARS are missing and the previous case manager is no longer with agency and they don't know what happened to MARS, none of the other nurses on the case were asked to go the office. I was always meticulous about signing for all meds I administered. I find it very strange and I don't see how I can sign for 3 months of meds that I gave, how can I remember that? Is that even legal what she's asking me to do? I'd really appreciate some input. Thanks

I believe it is legal, missing or messed up records are recreated or fixed all the time. But the story sounds very fishy, especially the part where you say the other nurses were not called to do the same. So who is going to redo their documentation on these three MARs? I would refuse to do it based upon the fact that the other nurses haven't recreated their documentation and there is no plan for them to do so.

Absolutely no way. No way.

Who knows what happened to them and at this point you can't possibly recall the details that would be necessary to do this. I will never recreate any missing documentation unless I can vouch for the truth of what I'm documenting. Documenting is saying "this is what happened." If you don't know/remember what happened, then you would be lying to document something. When you can't vouch for the truth of something you are documenting, you aren't really operating much differently than those who knowingly commit fraud.

If you no longer work for these people I wouldn't even speak to them about this. It is THEIR problem. If you are somehow put on the spot in person or on the phone, don't waver or ask any questions. Just say, "I'm sorry but there is no way I will do that." But ideally you would ignore them. If they text you or leave you a VM about their insane plan, all the better - keep any messages you receive.

No. Just do not do this.

Thank you so much for your comments

As for remembering what happened during those three months: I know, at a stable case, whether or not I have given all meds at their scheduled times. That info does not change from day to day. As long as I know which days I may have missed work altogether, I could figure this out. But if I know that there was an instance that there was a deviation from the scheduled meds, I would not be able to accurately recreate the record. I would not remember what day(s) this occurred. Three missing months and they just "discovered" it? Uh, uh, no. If you still worked for the agency, they would pressure you to produce the records. You no longer work on that case, or for the agency. Yet another reason to have forgotten the details. Their problem.

This is not a case of you failing to complete documentation, the agency lost months' worth of records.

One inaccuracy and you've just either falsified a record or *missed* giving a med. Even if you considered doing this, you'd have to have a 100% accurate and plausible recollection to make late entry documentation.

And even though I could understand feeling confident of giving ordered meds that hadn't changed on any of the shifts that I worked, it isn't plausible to accurately recall 3 months' worth of care 6 months later. Imagine yourself trying to defend doing so.

Specializes in Critical Care; Cardiac; Professional Development.

That would be a hard pass on my account. Their losing documentation in no way obligates you to recreate it.

That would be a hard pass on my account. Their losing documentation in no way obligates you to recreate it.

If you continue to work for the company, rest assured you would not, or should not, continue in their employ if they insist you "remember" what their negligence in the office brought about. After all, why did it take this long to figure out the charting is missing? I've been strong-armed to redo charting in the past and it never turned out well. Cover the employer and one still ends up without a job, but the employer is "lookin' good", which is all that matters to them.

Specializes in Geriatrics, Dialysis.

How does a health care company lose 3 months worth of medical records?? Anyway, it's not your fault they managed to and it's certainly not your responsibility to bail them out by recreating the lost documentation. There is no upside to this for you, basically you would only be doing it to help your former employer out of a pickle. I have no idea what the possible consequences are for a company that misplaces several months worth of medical records but I would bet there are some. The only way I would ever consider doing this is under court order with a lawyer right by my side assuring me that every recreated page of documentation was indeed legal and within acceptable practice though I doubt this company could provide a lawyer willing to sign off on the legality of this.

Another silly but pertinent question, recreating 3 months of lost documentation would be somewhat time consuming were you to actually agree to this, since you no longer work for this employer how are they planning to pay you for your time?

Specializes in Emergency, Telemetry, Transplant.

I don't think it is illegal, per se, to document this far after the fact if you note that it is a late entry. Then again, I'm not a lawyer, so don't take that to the bank. However, suppose something happened to the pt in the interim. It is going to look very fishy in a legal proceeding that a nurse signed the MAR so long after the med was passed.

This is the agency's problem. Get their request in writing, so you have a paper trail...and then say "no."

I'm reminded that if it isn't documented it didn't happen. However, asking someone to sign something the next day or even within a reasonable time is one thing. This is completely different.

I agree with the poster who said to get something in writing so you have a paper trail when you refuse.

Specializes in Travel, Home Health, Med-Surg.

As others have stated I would most definitely not sign any documentation this far out and reason being the agency lost it. I would also document (in personal records) of the date of request, the person requesting and the agency statement re: lost documentation just in case something comes up later, you never know.

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