Legalities of Paper Charting

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Hello! I work at an ambulatory surgery center where we have paper charting. After surgeries a few days ago, I was reviewing charts and noticed that another nurse had charted under my name that I had given medication to a patient after their procedure. I did not give this patient any medication whatsoever, as they had declined. This was noted as such; however, the nurse had drawn a line through it, put my initials and charted the med. The pen color and writing were obviously different. I immediately brought this to my supervisor's attention. The person who charted was identified and the situation was written up as an incident report with her name on it. Here are my questions...is that really an incident? From my standpoint, she's a licensed medical professional who falsified information and passed it off as someone else's. And only an incident report is filed? Is this like a slap on the wrist? Does anyone know the legalities of this? Should I contact the board of nursing in my state? I'm concerned because a little part of me thinks she's done this before to others, but no one has caught her until now. Thank you for any feedback!

 

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16 hours ago, FLmama said:

The person who charted was identified and the situation was written up as an incident report with her name on it. Here are my questions...is that really an incident?

Yes. Everything else notwithstanding, this is internal process is going to go on in any place that cares about anything.

IMO the one thing you need to follow through is the fact that, as it stands currently, the record is not accurate and your initials are attached to the inaccuracy. You do have an interest in the portion of the record with your initials attached to it being accurate. If it were me I would express this to your supervisor and ask how the record is going to be noted to reflect the fact that you did not administer that medication. I would probably pretty much insist that admin either correct the record themselves, or show you proof that they have had this other nurse correct the record (hopefully on her way out the door).

You will have to make your own decision about contacting your board or personally reporting another nurse to the BON. It is very likely that all of this boils down to her word against yours.

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Specializes in Tele, ICU, Staff Development.

Was this pain medication by any chance? If so, the narcotic sign-out should give more information.

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Thank you, JKL33 and Nurse Beth for your responses.

Apparently, today the nurse completed an incident report. So, she's still currently employed. The nurse has been with this place for about 15 years and has a close friendship with the DON. I was in surgery all day so by the time I was done, my supervisor had left for the day. We are planning to meet tomorrow when I will see how this is being handled. 

The medication is Diamox. Unfortunately, this medication is not in our daily med count; only narcotics. However, we need either the surgeon's or anesthesiologist's written/verbal orders to obtain it. So, somehow this was obtained. I have no idea. All of it is sketchy. 

Thank you both, again for your responses!

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Specializes in Mental health, substance abuse, geriatrics, PCU.

Diamox doesn't seem like something that would be a hot item for diversion but sometimes nurses divert very strange medications. I new a girl that got fired because she diverted a month's supply of oral metoprolol. 

I would however, be very disturbed by the fact that she did that and my ability to trust this individual would be non-existent. Your options may unfortunately be limited if she's a long term employee that is in good with management. Did you ask her why she did it? I think I would have to, who knows maybe there's a half way legitimate reason for what she did that we're just not thinking of? I do think from here on out, you're going to have to go over things with a fine toothed comb. Hopefully this was just a one time occurrence. 

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TheMoonisMyLantern, yes, you are correct, it's not a hot item for diversion. Here's what happened: During surgery, the surgeon told that nurse to give the patient Diamox after the procedure. She forgot. I happened to be working recovery that day. Later that day, she must've remembered because she went back into the chart, charted that I gave the med while in PACU (I was never told the patient needed the med, nor did I give any med to said patient for that matter.) So, instead of coming clean once she realized this, she falsified the chart, obtained the med, wrote down the patient's address, and drove to the patient's house to give the med. It's beyond ludicrous. This nurse STILL has her job. The chart was corrected to show that I did not give the med (this is the only part I'm happy about.) I realize nothing is going to change where I work, so I'm currently pursuing other opportunities. It's unfortunate because I really do enjoy the job. 

Thanks for responding!

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1 hour ago, MOmama said:

So, instead of coming clean once she realized this, she falsified the chart, obtained the med, wrote down the patient's address, and drove to the patient's house to give the med. It's beyond ludicrous. This nurse STILL has her job.

Come on!!

Wow.

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Specializes in Mental health, substance abuse, geriatrics, PCU.
On 1/27/2021 at 4:21 PM, MOmama said:

TheMoonisMyLantern, yes, you are correct, it's not a hot item for diversion. Here's what happened: During surgery, the surgeon told that nurse to give the patient Diamox after the procedure. She forgot. I happened to be working recovery that day. Later that day, she must've remembered because she went back into the chart, charted that I gave the med while in PACU (I was never told the patient needed the med, nor did I give any med to said patient for that matter.) So, instead of coming clean once she realized this, she falsified the chart, obtained the med, wrote down the patient's address, and drove to the patient's house to give the med. It's beyond ludicrous. This nurse STILL has her job. The chart was corrected to show that I did not give the med (this is the only part I'm happy about.) I realize nothing is going to change where I work, so I'm currently pursuing other opportunities. It's unfortunate because I really do enjoy the job. 

Thanks for responding!

Wow... What was this person thinking? As you said, it is beyond ludicrous! I think you are making the right decision with getting away from there!

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