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Discussion

missing documentation

I'm a brand new Director of Cllinical Services:) One of our nurses doing a chart check discovered that a recently fired nurse did not have her nursing visit notes in her charts. All gone! Disappeared! What recourse do we have? She has already collected her final paycheck. Is there a charge we can file to "force" her to give us the proper documentation?

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    Report her to the BON? Get risk management/facility lawyers involved? The notes do not belong to the individual or even the patient, they are property of the facility.

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    • Expert

    I would make one request by certified mail. No response within seven days, report her to the BRN. Consult with your risk management. BTW, in home health, I often see where nurses don't bother to provide their charting in the field chart. The supervisors never do anything about it.

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    • Expert

    Oh. I think the charge would be theft of property. Your risk management should follow up on this.

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    Was the charting removed, or never done?

    If actually removed, involve risk management. Removing patient documentation from the chart & premises is likely a HIPAA violation.

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