My Documentation Disappeared...?

[Fyles]

I've been a nurse for 15 years, and was always instructed...from day one...chart what you KNOW. So, here's my sitution:

I work in long term care, nursing home, and was working the other night from 7p -7a. Got called to a residents room when the CNAS were undressing a lady for bed and discovered swelling and dark purple bruising to her right ankle/side and top of her foot. The lady is wc bound, does not walk. She had been sitting in her wc, by her bed, since I came on the hall at the start of my shift. I did the routine actions for the situation...assessed for injury, called doc, family, etc. and started my documentation, including the Incident and accident report. I filled out all areas of the report the best I could, but the one thing that bothered me was that I could not identify exactly how the injury occured, as I did not witness what happened...much less, when it happened. Obvious swelling and bruising to that extent made me to think that whatever happened must have happened a day, possibly two, before. My best guess would be perhaps she turned her ankle. But she doesn't walk. I was always taught you NEVER "guess or assume" what happened. So I documented that the resident was found with the injury. I did not state a cause or what happened, because it was unknown to me.

So, the next day I get a text from my DON, stating that there's not enough information in the I&A, and that she needed GOOD witness statements saying what "possibly" happened. I informed her that the resident was found with the injury, and that I did not witness the injury, so I couldn't state what happened. It was unknown to me. So I went in to work last night, and after my routine charting was completed, I decided to re-read the information I had put in the I&A from the previous day. To my surprise, my charting/documentation had completely disappeared...and in its place was someone else's documentation of what happened. And it told a completely different story. They claimed the "slight bruising" was possibly caused by hitting her ankle on her wc. And that after investigating, she was no longer able to transfer properly, so they changed her to a full body lift. Granted, it all sounded much better than what I had documented, but it was not MY documentation. Another nurse completely deleted everything I had charted and put in her own words, and she wasn't working the night the injury was found. The only thing remaining from my documentation about the event is the I&A note that I had to do while filling out the report. The original report was electronically signed by me, that night. The new one had no signatures. Yet. Where did my documentation go?

My question is, how do I handle this situation? I'm waiting for them to tell me that I have to sign off on the I&A report...but I will refuse to do that, because it isn't MY documentation any more. And no one asked me or told me that they were going to add/delete my charting from the report. To me, this is highly unethical. I've only been working here a couple of months, but I'm seriously reconsidering my place of employment at this point. I'd gladly welcome and appreciate your thoughts on this situation...

[Here.I.Stand, BSN, RN]

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]

Exit, stage left!

[Tenebrae, BSN, RN]

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