is this legal?

[Ms.RN]

i work in ltc facility and one day my resident had a fall and hit her head and had to be sent to the hospital for sutures. i charted everything in her chart about the fall and notification of physician, family and neuro checks. obviously i filled out an incident report. i worked the next day and i checked nurses note and to my surprise a nurses note i charted on about her fall was gone!! few monthes after another resident had a fall and ended up sending to the hospital and patient ended up dying few days later and we were reported to the department of health. so we are expecting state surveyors to come to our facility any time soon to investigate. i watched all the unit managers and don take charts of patients to the conference room and they were looking at nurses note. one of the person i work with told me that whenever patient falls don doesnt report it to the state and edits the nurses note. is this legal??????

[ky_grl82]

I am a lowly CNA who *just* got into the RN program on rolling admissions for next Spring, so please know that this is mostly intuition I am going by. This is absoletly against the very little I learned about charting in my CNA course. I learned that there was a procedure for correcting errors in charts and NEVER actually remove any documents or notes. The pt has a legal right to see their medical records and to me it is obvious that removing things from the medical record is not legal. The hospital is covering their butt and trying to avoid blame in a lawsuit. POSSIBLY, they are keeping the notes and accident reports for safekeeping elsewhere to make sure they don't get lost. That is about the only positive reason I could think of for removing them.

[heart27]

WOW, Im glad that the facility is being under investigation. It sounds like someone is trying to prevent the facility from shutting down.

[Not_A_Hat_Person, RN]

Sounds like a cover-up.

[Bug Out, BSN]

You cannot edit someone's charting. You cannot remove part of the chart. Incidents MUST be charted or it is considered conspiracy to conceal.

If someone is editing your charting or removing it you are obligated to report it immediately. To fail to do so makes you legally liable and a party to the conspiracy.

Contact your BON immediately.

BTW make sure to get insurance, if I was a lawyer everyone and their mother would suddenly become poor.

[mamamerlee, LPN]

Simply put, not legal.

[RNgonewild]

Nope.

[tewdles, RN]

your instincts are correct...they may NOT remove or edit your nursing notes. It is time for you to practice some sincere CYA cuz there is going to be some trouble in your place of employment.

[PostOpPrincess, BSN, RN]

Absolutely not.

[pennyaline]

i work in ltc facility and one day my resident had a fall and hit her head and had to be sent to the hospital for sutures. i charted everything in her chart about the fall and notification of physician, family and neuro checks. obviously i filled out an incident report. i worked the next day and i checked nurses note and to my surprise a nurses note i charted on about her fall was gone!! few monthes after another resident had a fall and ended up sending to the hospital and patient ended up dying few days later and we were reported to the department of health. so we are expecting state surveyors to come to our facility any time soon to investigate. i watched all the unit managers and don take charts of patients to the conference room and they were looking at nurses note. one of the person i work with told me that whenever patient falls don doesnt report it to the state and edits the nurses note. is this legal??????

are you very sure that what you think happened is what actually happened? after a serious fall, administration will often review charts and take and copy documentation related to the incident. did you check the chart at any time after you noticed your note was missing? it might have been put back.

by the way, did you happen to mention in your note that you'd done an incident report?

if you saw the don and managers taking charts for review after a fall resulting in fatality, don't be surprised. that was a reportable incident and the facility was required to self-report the event. further, every facility i've worked in has responded to the possibility of ensuing investigation the same way: chart audits.

finally, i've learned over the years that if one coworker tells you something uncomplimentary about your employer, take it with a grain of salt. your don is not required to report every fall to the state, and it would be unfeasible to edit each and every chart note regarding falls. it would also be terribly obvious if the notes were edited.

[Not_A_Hat_Person, RN]

By the way, did you happen to mention in your note that you'd done an incident report?

At my job, we were specifically told not to write "incident report filed" because incident reports are not part of the chart.

[teeniebert, LPN]

At my job, we were specifically told not to write "incident report filed" because incident reports are not part of the chart.

This is common--incident reports are for the facility's use only, for tracking and quality improvement. However, there are usually other places that all the info from the incident report needs to be recorded. We have a change in mobility form, fall risk assessment, skin assessment, neuro checks, 'falling star' precautions, etc. that all have to be filled out any time there is a fall. The only info I can think of (off the top of my head) that goes on the IR and nowhere else is the staff information--where was the resident's aide at the time, where was the nurse, what else was happening.