Legal Documentation

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Specializes in Med/Surg, Forensic Science.

At the hospital I currently work at, Joint comission reviewed all the Nursing documentation and sited us on not having all enteries date & timed thus making us non-compliant. Our Nursing manager is now requesting that staff go back & "time" all enteries for medical records dating back 3 months ago. My concern is the legal liability if we go back and make additions to the medical record (which is easily visible by variance in pen inks etc) and add times (for care we provided 3 months ago) are we setting ourselves up for legal implications if the chart would happen to go to court?

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Specializes in Long Term Care/Mental Health.

We are also having that issue, and like you i am concerned with it. It seems very precarious to me. Another thing that is happening is care is beigprovided as a "help" to the next shift but not being documented in the flowchart. Thus the following shift is filling out the chart and signing it. I am very disturbed by this, and will not do it, but it is the norm, its expected and not usually questioned. What is the general thought on this?

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Specializes in Emergency, Cardiac, PAT/SPU, Urgent Care.

Technically, you are altering a medical record by going back and writing in new info - so I would agree that it is wrong (but I am by far not a legal person). Just my thoughts on it.

Also, there is no way you could remember the exact times of the care you provided 3 months ago. By writing in a specific time (and accidentally it is way off), you might be setting yourself up for trouble should a potential lawsuit ever come about.

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Specializes in home health, dialysis, others.

Generally, if they return to do another audit, they will look to see if there is a change in the more recent documentation. How can you write in times for things that took place months ago - absurd.

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Specializes in MDS/Office.
At the hospital I currently work at, Joint comission reviewed all the Nursing documentation and sited us on not having all enteries date & timed thus making us non-compliant. Our Nursing manager is now requesting that staff go back & "time" all enteries for medical records dating back 3 months ago. My concern is the legal liability if we go back and make additions to the medical record (which is easily visible by variance in pen inks etc) and add times (for care we provided 3 months ago) are we setting ourselves up for legal implications if the chart would happen to go to court?

OMG!!! I would think this would be highly Unethical & Illegal!

I would not have any part of this.

Report this Manager & notify the Legal Dept. :eek:

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Specializes in ADON,ICU,home health, LTC.

Your facility is required to be compliant with the corrective action plan that was generated in response to the cites you received. Your facility is not required to be chart compliant prior to the date the problem was identified and you were cited. It absolutely puts you in a terrible/vunerable position to alter a legal medical record after the fact. This is not a late entry. Did your nursing management educate the nurses in response to the cites you received? And if so from the cite date forward why does it continue to be an issue. Remember when it comes down to it your license will be on the line.

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The short answer is "yes". Likely, not. But still possible. Most of the time when there are issues like this, the DON will have people correct the records in a timely manner, near the time of the original entry. Three months later, upon the findings of an outside party inspection, shows that the DON, ADON, and medical records person, as well as supervisors, have not been doing their jobs when it comes to monitoring documentation.

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