My Documentation Disappeared...?

Nurses General Nursing


You are reading page 2 of My Documentation Disappeared...?

Specializes in SICU, trauma, neuro.
Correct me if I misunderstood, but incident reports are for internal use of the facility, not part of the medical record. So a nurse deleting your statement and adding hers would not be falsifying a medical record.

That said, still shadey in my book. Did she sign it with her name at least? I'm assuming she did, if you known who wrote it. If the report is generated in your name and they ask you to sign off on it, I would refuse as well. As for CYA, I would just make sure you documented what you found in the medical chart.

I was taught that as well, but the moment you mention "incident report" in the notes, they are fair game. However the falsification issue I was referring to was deleting the *nursing note* from the EHR. Someone falls, you are going to chart the story and assessment, not just complete an incident report.

morte, LPN, LVN

7,015 Posts

Exit, stage left!

Tenebrae, BSN, RN

1,888 Posts

Specializes in Mental Health, Gerontology, Palliative.

I had a situation where a patient developed a deep tissue pressure injury. According to our policies this is a notifiable event both internally and externally to the ministry of health.

A certain manager told me in all seriousness "well, we know its a deep tissue pressure injury but we'll leave it as a grade 1"

Now, no matter which way one looked at this pressure injury, there was no way in a turkey's thanksgiving it was a grade 1 pressure injury. I flatly refused to change my notes and continued to refer to it as a deep tissue pressure injury. Doing the notification was outside my pay grade, but I thought if anything happens and they want to read my notes, I'm not having this disaper or anyone ask me why I was calling it a grade 1 pressure injury when it very clearly wasnt.

In the event there is a risk of your incident form going missing, document the hell out of it in the patients notes. Continue to document what you saw, experienced, assessed, keep copies of your notes. And if anyone asks you to change your documentation politely advise them "that will not happen"

And consider looking for a new place of employment. The above is all very well and good, it may get you with a very large target on your back for doing what is right

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