Nursing Documentation - Lost!!

[Karla.S]

Hi! I've got a bit of an ethics questions I suppose..

I work in a psychiatric hospital. One night, we had to apply restraints for Pt. safety. We do 15 minute observations on the Pt and check vital signs as well. Someone during the night had misplaced the 15 minute observation sheet and HIM has been looking for it. (I'm a tech there and am in nursing school currently). The RN for our building told my supervisor to "just print out a new sheet and have them fill it out" and my supervisor agreed that this was a good idea... I'm not too keen on that because, to me, that seems like false documentation because it could not be 100% accurate. I sent an email to the ADON about this and am waiting on a response...but I thought I'd ask what you all thought about it. Am I wrong to not want to put my name on a piece of paper that is essentially "back-dated"?

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

That's always a tough call, especially when management goes along with charting that isn't timely. I've fought that battle before. My final answer is already in your question. Document what you know to be true. The 15 minute checks and vital signs were done, the patients response, and that the original documentation is unavailable. The biggest problem with the "just print a new sheet and have them fill it out" is that if there were some kind of legal action, then like airline luggage and 1 sock from each load of laundry, the original charting would appear out of nowhere and then you're in deep yogurt trying to explain any discrepencies.

[anonymous1919, LPN]

If you know you did in fact check him... couldn't you fill that part out and leave the v/s part blank? That's what I would do.. and write the date of today and also write (for: 1/1/1 *date its for*) so it's clear that it's a new copy. Kind of like making a late entry.

[brownbook]

I would fill out an incident report.

On the "new sheet" I would write in big bold letters at the top something to the effect of "late entries, due to original document lost (or misplaced)". Then document what you could on the new sheet. You would have to leave the vital signs blank.

[KarmaWiseRaven]

I love all these textbook answers i really do. When you know darn good and well you would just make up another sheet. Things happen i worked Psych and we have lost check papers even when they came out of restraints and gone on a 1on1. We just make a new sheet but charted this is not the original paper but everyone who has signed it was there and present that's all we would did. These are my thoughts use them as you wish.

[brownbook]

Karma, your answer is right, as is the comment about the text book answers. Unfortunately lawyers have a hand in writing those text books. It all seems to come down to how will it look in a court room with a lawyer asking you about this lost document. Forget plain old common sense!!!!!

[JoytoWorld]

Consider your objectives:

First - Accurate data for continuity of care.

Then make a notation that indicates the unique circumstances: "late entry" or "addendum" or whatever. In this case it is both "late" and an "addendum". Indicate why the document is not the original. If someone in higher authority ordered the action, include that information. Then document what you can that is accurate. Example: "Late entry. Addendum. Original document reported as lost. Supervisor X notified and order given to write addendum. Client observed every 15 minutes by me. Vital signs performed and remained WNL. Client remained safe and secure."

If you feel that is not enough or in any situation where you are uncertain of the ethics around you, send yourself an email on private NON-COMPANY email to date/time your observations. Seek advice from someone that you trust OUTSIDE the facility if you think you need to report the actions of a superior. Such actions will nearly always mark you and jeopardize your employ unless you work with divine creatures free of normal retaliatory emotions. You need to see beyond the moment for the potential effects of your actions. The document was already lost, there was time to seek advice.

There are supervisors who will ask you to do unethical or illegal actions. Don't do it. Document to your self and seek advice. In this case late addendum is not unethical; if it clearly indicates the circumstances. In my opinion this situation does not rise to the level of an incident report. What was lacking was good supervisory advice on how to perform accurate documentation when the original was lost. Any jury or judge would comprehend the notation: "late addendum, original was lost."

[carolmaccas66, BSN, RN]

This happens on our psych unit. We document obs as to where and when the patient is at certain times (ie: every hour or 2 hours). Most times, nurses 4get to complete these because they get so busy.

It's illegal to document things/obs/events you haven't seen or done. I leave mine blank & continue charting. If a sheet is lost (and it does happen everywhere), you just write at the top of a new one 'original chart misplaced' and continue your obs. We have had this happen with missing med charts as well. Don't continue putting down obs etc u can't remember. U will put your job on the line and it is illegal, in Aust anyway.

[nurse2033, MSN, RN]

As long as the documentation is true and accurate, not a big deal if done after the fact.