Manager wants me to alter documentation on expired patient

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I recently took care of a very critical patient who was not expected to survive (septic shock, DIC) who was to receive multiple units of blood products. The patient expired before the transfusion was complete so on the form I checked off the 3/4 box as that the transfusion was about 75% complete and indicated that patient expired before transfusion could be completed.

my manager does chart review and approached me and says that it was inappropriate to chart this and that I should have wrote all vital signs as "0" on the form and wants me to retrieve the chart from medical records and change it.

i recently took a course in critical care nursing and nursing documentation and approached the speaker who is a legal nurse consultant and has sat on numerous legal cases and asked her opinion.

she said that there is nothing wrong with what I wrote, it is accurate and I cannot document v/s as "0" if I coded the patient because not v/s were taken! It was a code! She was adamant I do not alter my documentation.

how do I now approach my manager?

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Specializes in Neuroscience.

I would ask her how she would like the falsified information to look in the chart. That'll stop her. Also, ask if her last name is maiden or married, because you would like the note in the chart to match her nursing license (If she continues insisting that you do this).

The moment you throw out "you" and "falsified information" she will back off.

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Specializes in Critical Care.

I'm not getting what it is your manager wants changed, does "0" refer to charting that no vital signs were done or that the patients heart rate, BP, etc were "0"?

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He wanted me to chart that the patients vitals were "0", as in that the patient had no temperature, HR, or BP.

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I am so confused. I have never written vital signs as 0. It does seem like that could mean none were taken? Is that what she really wants? I'm not sure what a 3/4 box is and what the 75% PRBC has to do with any of it?

I understand your frustration or annoyance. I would take a few deep breaths and approach the manager in a calm, we can figure this out, maybe my charting was confusing, way.

I am not a legal expert but I think you can add an addendum to a chart that simply clarifies what and when things happened if it unclear from your original charting?

Of course you don't alter your documentation.

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Are your patients not hooked up to monitors the entire time? Is this an ICU? If you "coded" the patient you had to have gotten vitals.

Technically, the infusion did finish. Why would you infuse into a dead person?

I don't see marking the vital signs as zero, which they would have been at death, is falsifying documentation. Am I missing something here?

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I am so confused. I have never written vital signs as 0. It does seem like that could mean none were taken? Is that what she really wants? I'm not sure what a 3/4 box is and what the 75% PRBC has to do with any of it?

I understand your frustration or annoyance. I would take a few deep breaths and approach the manager in a calm, we can figure this out, maybe my charting was confusing, way.

I am not a legal expert but I think you can add an addendum to a chart that simply clarifies what and when things happened if it unclear from your original charting?

Of course you don't alter your documentation.

Yeah, I was kind of wondering what this 75% box is as well.

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Ask if your manager and the hospital's risk manager can meet with you to discuss this situation. Explain to the risk manager that you do not think it looks good from a legal perspective to pull the chart from health records and alter the charting after the fact, ask what does the risk manager think? ( I'm pretty sure they will agree with the advice you received from the legal nurse consultant).

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This is just a shot in the dark, but I'm thinking there may be some QA tool that flags every infusion that doesn't have post infusion vitals and then it goes on some "naughty list" or something and she doesn't want one for her department on it. I've seen how these excel reports are generated and then reviewed. Now, it would be nice if they went back and looked at additional notes charted that may explain why they were not documented.

Yes, the pulse and b/p will be 0 for eternity ...but the temp? No room is that cold. Okay, now I'm being a wise ass but I just cannot stand some of the stuff that comes out of chart reviews that could easily be waved if they actually REVIEWED the chart.

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But the temp wouldn't have been zero. She would have been a popsicle for that to be the case.

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But the temp wouldn't have been zero. She would have been a popsicle for that to be the case.

And if that chart was ever brought up in court you know some lawyer would zoom in on that one. Right before I got my license years ago a lawyer had deposed all the nurses for in the chart. The questions asked had nothing to do with the outcome of the patient. He was digging for something, they just had no idea what.

We just don't check body temps on dead people. It's irrelevant to their care, as would be physically checking BP and pulse at that point.

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Specializes in Mental Health, Gerontology, Palliative.

What I did in a similar situation with a patient with a deep tissue pressure injury who the clinical manager wanted to document as a stage 2 pressure injury

I advised I would continue to document my nursing assessments as I saw them. If management felt that there was an inaccuracy or incorrect information they were welcome to add an amendment.

Fortunately I didnt need to point them towards our nursing council code of conduct

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