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Medical documentation issue

Posted
basha basha (New) New

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.

get a lawyer...... NOW

You gave 1/2 of med ordered :confused:

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

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

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.

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

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

Specializes in Orthopedic. Has 2 years experience.

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

Specializes in Emergency/Trauma/Critical Care Nursing. Has 11 years experience.

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...

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