Medical documentation issue

[basha]

Hello all,

I've been an RN for 22 years, and until now have never violated the rule of altering a document by writing over. Well, I did it this week....I'm aghast and shocked that to do such a thing would ever cross my mind!! It was on 2 injections that I gave in the past 2 months (1 every 4 weeks). I saw that I had written I had given half of the dose ordered per the Dr., and without thinking, wrote over my handwriting to reflect the full dose. The next day I was terminated for doing this. Some background; I hated the job I was at, and was overwhelmed and unsupported by everyone I worked with. Anything I did was never enough, and never correct....I had a total hysterectomy this past April, returned to work June, and went thru complete menopause due to not being able to take HRT. I realized my thoughts and feelings weren't like they used to be, and the daily anxiety of simply going to work put me into a near panic. No harm came to the patient, but I was clearly wrong in what I did. I can't even explain why in the world I would do such a thing...please give me feed-back on the possible repurcussions of this action. My husband told me he was glad I was out of that place, but I'm worried sick about my liscense. I've never ever done anything like this before!!! Please help me assess what I need to do. I live in Michigan. Thanks in advance.

[Rena RN 2003, RN]

?

contact your lawyer.

[KKERRN]

If you carry your own malpractice insurance....you need to contact them also. They may provide a lawyer for you.

[Kireri]

get a lawyer...... NOW

You gave 1/2 of med ordered

You altered the chart......to reflect a larger dose given......weeks later

yup, get a lawyer...... NOW

[tonchitoRN]

get a lawyer just in case. the facility may just ignore it and not report it. if they report it they will be opening a can of worms. some facilities would rather shove it under the rug. good luck.

[FlyingED]

One night in the ED we had a two person MVA. During my assessment I asked whether the patient had been drinking. His reply, instead of yes or no, he replied "I had six drinks" I normally only chart + or - ETOH. But, when the patient tells you how much, you chart it.

Well what is funny, a couple weeks later the patients mother calls the ED director wanting the chart changed by having the ETOH reference deleted. My director told me the story and we both had a good laugh. It goes along the lines "if it wasn't charted it didn't happen, then if it was charted it did happen":chuckle

[athomas91]

i would get a lawyer - however - many nurses caught red handed stealing narc's are fired - but their licenses are not taken - if this is your first offense - just state you know you were wrong - you had never done anything like this before and that you STRONGLY REGRET doing it - i think your license will be ok.

[Mingma]

Please, do not sit hoping the facility won't complain it. Keep in mind about MDS and just hire a lawer! Step on it right now!!!I hope everything will be fine!!!

[Christy1019, ASN, RN]

hmmm... i'm thinking that since this occured 6yrs ago (the original post was october 2003), that the issue has probably come to some sort of resolution by now lol. :lol_hittii didn't see the original date at first but when i clicked on the thread starters name i saw that she had a post in another forum from oct 03 for the same issue and i was thinking Wow, how often does she do this? lol then i put it together.... wonder what came of it though...