Nurse manager requests a change in my documentation

[mommy#1nurse#2]

I am an RN working in home health- I was recently involved in a case in which I was informed by a caregiver that my patient (with dementia) had been sexually assaulted. I documented everything that I had been told, filed adult protective services reports and had the patient transported for evaluation and sexual assault exam. Several days later I was informed by the director of nurses at my facility and nurse manager that the caregiver had lied about the situation. I received a note in my inbox with all of my documentation from the event with a request for me to modify my documentation to reflect that it had all been a lie.

I do not feel comfortable changing my documentation, as the documentation reflects what I was told, what I assessed at the time, and the interventions I made. In my opinion any information that is obtained at a later date can be documented by the person that obtains that information, but for me to go back and change all of my charting is wrong, and doesn't reflect the situation at all. it seems to me like it would be a big liability.

Does this sound like Im right? The manager is insisting I change my documention, and I am planning on heading to the director to explain my reasoning behind not changing my charting.

Thank you for your input.

[canoehead, BSN, RN]

You sound right. You could time and date for today, and write that you were informed by Ms x that the caregiver's statement was inaccurate. But changing what you wrote on that day would be inaccurate and confusing for the reader, not to mention illegal.

[Batman24]

You're right. That's illegal. You can state what you were told by X that the info was inaccurate on the date and time you were actually told but you can't and shouldn't change what you originally wrote. You took the appropriate action based on what you were told.

Your manager knows better than to even ask you to do it. Under NO circumstances would I alter what I wrote. Shame on her for even asking. She's knows it's illegal. Continue to stick to your guns and don't let them bully you. Something is stinky here and I wouldn't be a party to it.

[BelleKat, BSN, RN]

yes,definitely stick to your guns regarding not changing what is already on the medical record. they definitely know better than to ask you to do that,it's illegal and would cast a very bad light on you if it should go to court. i'm not saying that it will,always cya.

[Daytonite, BSN, RN]

omg! what a numbskull. i can't believe that a manager would even ask someone to do that. it makes her look suspicious and guilty. does she have a boss or is there are risk manager in your company? i'd complain to her boss in writing that she has asked you to falsify a record which puts your license in jeopardy and is unethical. i would put that in writing as a memo to her boss and keep a copy for yourself in case that chart ever ends up being tampered with later on or you decide to file a complaint against her with the state board of nursing, medicare, or the agency who investigated the abuse. if the company has rules about falsifying records and the owners have any guts, they'll send this woman packing out the back door. she needs to be run out of the business. this is incredible.

[Tash4nvyblues, RN]

That is incredible, you have done all the paperwork and appropriate interventions that you need to in this situation. Your nurse manager should be documenting the conversation and all related outcomes from that conversation, not you, and you should not alter or touch your documentation at all. That is mind boggling

[nursemary9, BSN, RN]

You are right.

When I did Home Health, I was asked by my Manager to change some charting. I was always taught that this is ABSOLUTELY not done & is an ethics violation.

My Home Health Agency had a Business Ethics HotLine that I called.

My problem was investigated & my Manager was subsequently Fired.

There was a notation made in my file commending me.

[Jolie, BSN]

I agree with the others. Absolutely don't change a thing! Make addendums as appropriate, but never remove prior charting. As the others have stated, your manager knows better than to ask you to do this, and so does the director. I doubt that you going to the director is going to change anything. She is probably behind your manager's request.

I have a hunch that your charting is about to "go missing", and I suggest that you make copies of it pronto to keep in a safe place.

[Altra, BSN, RN]

Just curious how your manager plans to account for the phone call to adult protective services, and the transport & sexual assault exam of the patient, if s/he "erases" evidence of the caregiver's origininal statement.

Events have occurred. Your documentation reflects them. To edit the original entries based on new information received at a later date is absurd.

[goshop74]

I would not change any of my documention or edit it. If your DON or Nurse Manager was told by the caregiver that it was a lie, then they should be responsible for charting it. If something was to happen and this case did go to court and you charted that Ms.____ RN reported to you that the caregiver lied about it and no sexual assault had happened, where is your proof that Ms.____ RN actually told you that? If they are wanting you to lie about this on a legal document then who is to say that they wouldn't lie about it in court. It is there responsibility to handle this matter not you. You done your job!!!!! Sounds like they need to do theirs. Two other nurses, myself, and my employer was slapped with a lawsuit in 2006 from a patient that we had taken care of in 2000. Myself and 2 nurses were investigated by the Ohio Board of Nursing because we had been the ones that had taken care of her the day she died (ALS). The family stated we denied her the right to breath. After reading my nursing notes and reviewing the patients chart I did remember the patient and the events that happened that day. My lawyer told me that the only thing that saved me was my charting. If you are like me and you depend on your salary and value that hard earned degree than take my advice and don't change anything. It's not worth it.

There is a reason they don't want to chart what they were told and it sounds like they don't want their signatures on anything that could come back and haunt them later.

[canoehead, BSN, RN]

Denied the patient the right to breathe? Crazy.

[zimsaint]

It is sad to say that this is a common occurence in nursing. I too would not change ANYTHING. Make a photocopy of your ocumentation if you can to keep for your records. Keep in mind you may be fired or harrassed to quit after you refuse your managers request. But what she is asking you to do is illegal and unethical; you can report her to the BON.