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.

[Jolie, BSN]

This entire situation stinks to high heaven. Someone acted on information regarding possible abuse, went thru the proper channels to document and alert the authorities, and is now being told it was all a lie.

How about the possibility that it is a factual allegation, but the family/ caregiver is now trying to change the story to avoid the scrutiny of an investigation, and the agency is pressuring the nurses to go along with the "revised" statement in order to avoid upsetting the family and keep the case active, which means income for the agency?

If my suspicions are correct, your documentation may be the only protection this patient has in order to get protective services involved, and get abusive caregivers/family members out of the situation.

Not only would changing documentation be illegal in terms of altering a legal document (the medical record), it would constitute interfering with an investigation that may ultimately leave a vulnerable patient unprotected from abuse.

[withasmilelpn]

Don't do it! If she obtained that information that the person lied, SHE needs to document it. This is only hearsay to you, and will not protect anyone anyway. It is a third party statement, one not heard by you, and is unadmissable. Plus it does in fact make you look bad. Stick to your guns, the law is on your side. Good luck!