Is it legal to write a order 4 months after you took it?

[BigSurKay]

I work at a psych hospital and the order I wrote for a seclusion and restraint was misplaced. My DON is asking me to write a new one and have the MD sign it. I took this order over 4 months ago.

What do you think? Am I splitting hairs?

And how would I date it? Would I write the current date or the date of the occurrance?

Thanks.

[Creamsoda, ASN, RN]

I dont think I would be doing that. Its so long ago. Hopefully your charting is adequate enough. I dont think you can go back that far to back chart. Im sure it wouldnt be considered accurate.

[Zana2]

What you are being asked to do is forgery.

A document issued 4 months ago and dated today is useless. But never sign anything with a previous date.

[loricatus]

It would be totally legal to write the order again, as you orginally wrote it (providing you recall this order); but, you would have to add a notation on it saying that it was a rewrite (for a lost order), with the date and time of the rewrite.

[ERRN92]

I agree with loricatus. If you remember taking the order, you can rewrite it as long as you document that it is being recorded at a later date. This isnt falsifying anything because the order is valid. However, any decent lawyer will probably try to argue its validity. The first thing they will check is your policy and procedure regarding late entries. Make sure you're within the guidelines. In any case, they cant prove that you intentionally created a false order as long as you have the Doc and hospital backing you up.

[caliotter3]

I agree with loricatus. If you remember taking the order, you can rewrite it as long as you document that it is being recorded at a later date. This isnt falsifying anything because the order is valid. However, any decent lawyer will probably try to argue its validity. The first thing they will check is your policy and procedure regarding late entries. Make sure you're within the guidelines. In any case, they cant prove that you intentionally created a false order as long as you have the Doc and hospital backing you up.

I agree with this. You remember taking the order. So you are not making anything up. Our DON rewrote nurses notes one time and started the narrative note by stating that she was rewriting an entry made by a nurse that only occasionally worked at the facility. The note that was originally written, was deemed inadequate by the DON, who was present during the event being charted on. I wondered about removing the original note, but she sure did remove it.

[Jules A, MSN]

Our DON rewrote nurses notes one time and started the narrative note by stating that she was rewriting an entry made by a nurse that only occasionally worked at the facility. The note that was originally written, was deemed inadequate by the DON, who was present during the event being charted on. I wondered about removing the original note, but she sure did remove it.

Thats interesting, and I've seen some notes that really should be re-written. I'm not sure how you would word that on the chat for the re-write by someone else though. I'm not a manager but I'd probably be inclined to have asked the nurse to re-write it herself and just discuss the changes that would be required before she re-did it.

[caliotter3]

Thats interesting, and I've seen some notes that really should be re-written. I'm not sure how you would word that on the chat for the re-write by someone else though. I'm not a manager but I'd probably be inclined to have asked the nurse to re-write it herself and just discuss the changes that would be required before she re-did it.

Knowing the take charge attitude of this DON, I could see her doing this instead of contacting the original nurse. That nurse rarely worked in the facility.

[Lacie, BSN, RN]

I agree with this. You remember taking the order. So you are not making anything up. Our DON rewrote nurses notes one time and started the narrative note by stating that she was rewriting an entry made by a nurse that only occasionally worked at the facility. The note that was originally written, was deemed inadequate by the DON, who was present during the event being charted on. I wondered about removing the original note, but she sure did remove it.

The appropriate would be to add an "addendum" to the original note without disposing of the original notations. You never remove any original documentation but you can add. You also dont back date. It can be written as "3/20/09 Addendum to nursing notation dated 12/03/08 blah blah blah, Josie Smith RN." In reference to late Orders can be written as "Late Order Entry for 12/02/08 Change Medication to blah from blah. 3/20/09 T.O Dr. Joe B/Josie Smith , RN."

[Bumashes, MSN, APRN, NP]

Not sure. I think my facility would have you write an order clarification instead and state within it that the med was began on such-and-such date originally. Then, of course, document your bootay off as to why it was written in this manner.

[CaLLaCoDe, BSN, RN]

I would not dare do that, what would you tell the MD when he or she states that she/he never did such a thing? One day in court not worth spending! Call the Doctor and get a new order. Situations change, clear it with the DOC. Don't be lazy period!

An order for Butt Paste, well so what??? For heparin, warfarin, insulin sliding scale? Forget it! Save your hide! Just make that call!