Manager wants me to alter documentation on expired patient

[All4NursingRN]

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?

[All4NursingRN]

Interesting question

It has always been my understanding that after 24 hours has passed you cannot add an addendum to the patient's chart or make any changes without any exceptions. Am I wrong in thinking this? If so, what she is asking you to do is not legal for a nurse to do, period.

[Ambersmom, BSN, RN]

Perhaps your facility has a policy on this, but I've never heard of a 24 hr limit on charting. I've done late entries 72 hours later, but they ard clearly documented late entries.

[Apples&Oranges]

One of the reasons this makes me nervous is that in EPIC, if I try to chart on or even LOOK at a deceased patient's record, a big red "warning" box flashes at me and says something to the effect of :You are trying to access the chart of a deceased patient. Are you sure you want to do this?

Now, I know part of the reason for that is to avoid wrong patient charting, but I've always wondered if it was also an indicator that charting or snooping in a dead pt's chart sends some sort of flag to the chart review people - like "breaking the glass" of an employee or other blocked patient. I've done it, but only when I really needed to, and I always write a note as to WHY I was in the chart of a patient that had a "deceased" status in the system.

[katfish67lpn]

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.

It is actually a good thing to chart that pt. has no BP/P, which of course you have to check before documenting such findings, as well as pupils are fixed & dilated. I have seen (once) a patient "pronounced" in a LTC facility when in fact that pt. was not deceased. The nurse on that unit had not checked BP or pupils and stated she didn't hear a pulse. This pt was actively dying so she just assumed she had passed. The nurse had to then tell the family that she wasn't actually dead yet..."Oops sorry for calling y'all in (as they requested) at 11:00 at night but umm, no she hasn't passed away."

I always check BP/P & pupils and document my findings.

[MunoRN, RN]

I don't ever chart vitals on the form blood bank sends, I write "see vitals flowsheet", if they were to code I would write "see code blue documentation".

I don't however see the problem with documenting that a patient's pulse for instance was "0" if the patient was coding at that time, I would hope someone had checked the patient's pulse and if a code was called then it was most likely absent, so zero would be accurate.

[MunoRN, RN]

One of the reasons this makes me nervous is that in EPIC, if I try to chart on or even LOOK at a deceased patient's record, a big red "warning" box flashes at me and says something to the effect of :You are trying to access the chart of a deceased patient. Are you sure you want to do this?

Now, I know part of the reason for that is to avoid wrong patient charting, but I've always wondered if it was also an indicator that charting or snooping in a dead pt's chart sends some sort of flag to the chart review people - like "breaking the glass" of an employee or other blocked patient. I've done it, but only when I really needed to, and I always write a note as to WHY I was in the chart of a patient that had a "deceased" status in the system.

The reason EPIC asks you this is to make sure you are pulling up the correct patient, since deceased patients don't need to be charted on all that much after they are deceased. That doesn't mean however that you can't complete appropriate charting on a patient after they have died, I chart on every single patient I have who dies after they die, the bigger problem would be if I didn't.

[aquakenn, CNA]

It's illegal and it's your license if it is caught. Tell your manager no because of those two reasons.

[wondern, ASN]

Tell your manager to blow it out.....sorry it just felt so good saying!!!!!!!

[All4NursingRN]

Update: I could not get onto my manager last week to tell him I was not comfortable making the changes (as he was out that week) I went to medical records and amended the form to say "please see EMR charting" so I guess the lab still was not satisfied with the amended changes and flagged it again. Last shift the manager called at 7am and told the clerk to ask me not to leave as yet (my shift ends at 7:30 am) he doesn't show up to work until 8:15a so I hung around for 45 min! As that I did not want to seem insubordinate by leaving.

He asked me what happened and I explained that I was not comfortable with the changes citing reasons mentioned in this thread. He then tries multiple times to convince me to see it from the laboratories point of view and alluded to the point that things are not always accurate but they should be done in order to follow standard procedure. He even says that I could have put any number in the temperature column to which I tell him that it is not standard of practice to take temps or any vitals on the deceased. He jokingly says it's not big deal and says that I am a bit stubborn but he thinks it's a good thing that I think things through (excuse me??? How rude)

It seems as though the entire thing is no big deal to him. I then begin to explain the legalities of changing documentation ( as that I was consulted not to make any changes by someone with a legal background) and how poor it looks to do so and he again just shrugs it off and continues to stress that the blood bank needs to see numbers on the form and suggests we both go to the blood bank so I could speak to the blood bank manager and in his words "tell her what happened", he also asks me who consulted me on this and asks if I could give him the info for the class where I met the legal nurse consultant as he would like to brush up on the legalities of nursing documentation as well (Smh)

We go down to the lab but the manager is not there, so now he seems flustered and ponders if he should go to MR to alter the form. I politely ask him if he will initial the form if he makes any changes to the document he laughs and say "no". He then attempts to back track and says he will not make the changes and will speak to her again and let me know what happens.

I have lost all respect for this manager, no one really respects him, even the director (his boss) is quite open about his distaste for him (what an institution!) I don't know what to do or say but in a week or two I will again request the chart from MR to see if he altered the form, and if he did make copies and bring it to HR to show what a deceptive person he is.

[All4NursingRN]

By the way I know some had said earlier in this thread that I should never leave the form blank, that is of course true. I looked the form over when I pulled the chart to ensure I didn't leave anything blank and I thankfully hadn't left anything blank.

In the last column where final vital signs are written, I wrote verbatim "patient expired before transfusion completed please see RN documentation" the form was otherwise complete.

[Wizard 1]

I can't readily find anything incorrect in your charting from what you related. I'm unsure why your manager is asking you to do this. Do you have a legal department in your facility? Ask them.

[dec2007]

Don't commit fraud for anybody!