Lying in a pt medical record

Nurses General Nursing

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Specializes in None, going for L&D.

Why would a nurse [or medical professional] purposefully lie in a patient's medical record?

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Specializes in Psych (25 years), Medical (15 years).

To CYA.

The old adage "If it wasn't charted, it didn't happen" could be interpreted by some as "If it happened, it happened the way I charted it".

Sic semper tyrannis.

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Specializes in Psych ICU, addictions.

First thing that comes to my mind is that the nurse, etc. is trying to cover up a mistake.

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Specializes in None, going for L&D.

Hypothetically. A patient comes in, willingly, via ambulance due to suicidal thoughts/attempt. Patient is a parent to a toddler and adamantly states child was nowhere near them at the time of attempt, while explaining what had transpired.

It is charted in their medical record "[patient] forced child to watch them commit suicide".

Why?

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Specializes in Complex pedi to LTC/SA & now a manager.
Hypothetically. A patient comes in, willingly, via ambulance due to suicidal thoughts/attempt. Patient is a parent to a toddler and adamantly states child was nowhere near them at the time of attempt, while explaining what had transpired.

It is charted in their medical record "[patient] forced child to watch them commit suicide".

Why?

Is this your record or that of your family? This is a very specific question

Was it noisy when the patient explained? (That perhaps in commotion that was what the provider heard, not is an easy word to not hear if lots of background noise. Perhaps the writer felt the patient was too adamant that the child was not present but the child appeared visibly upset and traumatized. If the parent was home alone with the child, made a suicidal attempt but called 911 resulting in emergency response waking the child for transport. The child would be distressed from being woken in confusion & commotion. A third party might see a distressed child, suicidal parent overly adamant the child did not witness the suicidal gesture (child could not witness parent commit suicide by definition if parent survived)

Was the patient lucid or altered mental status (whether due to medications or depressed state/suicidal ideation)? (If altered and distressed perhaps the explanation was jumbled and confusing to the listener)

The sentence made no sense. If the patient had suicidal ideation with an attempt clearly they are alive so how can a child be forced to watch someone commit suicide? Committing suicide results in death. Therefore the patient cannot make such a statement post mortem.

Either way one component of HIPAA is a right to request to inspect medical records and request corrections of erroneous information or at minimum add a statement challenging statements present that would become s part of the medical records.

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Specializes in Psych (25 years), Medical (15 years).

I'm going our on a limb here and interpreting the documentation as a manipulation of media in order to achieve a desired effect.

For example, an involved professional may have believed the child was in a dangerous situation and embellished facts in order to increase the severity of the situation.

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I'm going our on a limb here and interpreting the documentation as a manipulation of media in order to achieve a desired effect.

For example, an involved professional may have believed the child was in a dangerous situation and embellished facts in order to increase the severity of the situation.

And get CPS on board.

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Specializes in Oncology; medical specialty website.
Hypothetically. A patient comes in, willingly, via ambulance due to suicidal thoughts/attempt. Patient is a parent to a toddler and adamantly states child was nowhere near them at the time of attempt, while explaining what had transpired.

It is charted in their medical record "[patient] forced child to watch them commit suicide".

Why?

Why don't you just ask the person who "documented" this questionable statement, rather than speculating why?

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Specializes in Complex pedi to LTC/SA & now a manager.
I'm going our on a limb here and interpreting the documentation as a manipulation of media in order to achieve a desired effect.

For example, an involved professional may have believed the child was in a dangerous situation and embellished facts in order to increase the severity of the situation.

A single parent attempting suicide while only parent and toddler home, regardless if the child found or saw the parent attempt or contemplate suicide the parent put the child in harms way. If the parent succeeded and committed suicide s/he just made the child into an orphan and would have likely scarred emotionally for life waking up to find their only parent dead at their own hand. Definitely a mandatory report to CPS if a suicidal parent made an attempt/suicidal gesture while home alone the child was high risk. Telling mandated reporters such a scenario...you can't take that back no matter how much you protest

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Specializes in None, going for L&D.

That is scary, "if it happened, it happened the way I chatted it."

What if there is proof, via police report and witness statement, that part of the medical records is false?

I thought that lying within a medical record has major consequences for the person lying.

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Specializes in Complex pedi to LTC/SA & now a manager.
That is scary, "if it happened, it happened the way I charted it."

What if there is proof, via police report and witness statement, that part of the medical records is false?

I thought that lying within a medical record has major consequences for the person lying.

Then you file for a correction of the records as per your rights afforded by HIPAA. Instead of presuming malice perhaps what was written was heard. Or it was a voice to text system that was improperly QC'd before saving.

How do you want the person penalized that you feel misquoted you in the medical record?

What corrective action are you seeking?

What witness statements? Police & EMS records may not force a change as many people tell one story to police and first responders and when questioned while in the ED or by the psych screener totally change their story.

If you were home alone with a toddler and attempted suicide, regardless if the child witnessed the attempt or was asleep in another room, even if you changed mind and called 911, then the toddler was in fact in danger and an investigation by CPS would be mandated.

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Specializes in Pedi.
That is scary, "if it happened, it happened the way I chatted it."

What if there is proof, via police report and witness statement, that part of the medical records is false?

I thought that lying within a medical record has major consequences for the person lying.

Police reports and witness statements are not necessarily "proof." People change their stories all the time.

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