Published Aug 6, 2006
DemrixRN2000
15 Posts
I was notified a nurse last week that they were completing charting from the previous month. We are a JACHO certified faciltiy and I think this is fraudulent behavior. I really don't know what the next step shoud be but I am sure that there shoud be some follow-up. Any advice would be greaty appreciated.
Thanks
Otessa, BSN, RN
1,601 Posts
Doctors can put addendums to their H & P's. Nurses can write addendums as well. A slong as you aren't changing the ORIGINAL documentation......
someone correct me if I am wrong.
PANurseRN1
1,288 Posts
Or as long as it's noted as a "late entry."
JVanRN
406 Posts
Doctors can put addendums to their H & P's. Nurses can write addendums as well. A slong as you aren't changing the ORIGINAL documentation......someone correct me if I am wrong.
That's what I thought too. Our neonatologists have had to go back and add to medical records weeks after a baby is discharged. For example to document that they followed up with the family on an abnormal test result that may have take weeks to result (like a newborn screen). But it was always dated for that exact date.