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Discussion

Question regarding destroying documentation

I was wondering if anyone has any VALID information to offer regarding this situation......I live in Nebraska and work in a long term care facility, I charted on a resident on their daily wound assessment. When I was documenting this morning, I noticed that the page I had documented on had been removed and replaced with a new one, the information was re-written and the information I had documented had been removed. There is NO evidence of it being there..........I notified the DON, but she won't do anything. What do I do, where do I stand and that isn't legal is it?

Thank you!!

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    Completely illegal. Sorry, but I couldn't tell you how to move forward with this as you have already addressed it with your superior. Do you know who removed it and could discuss it with them? This makes me appreciate electronic charting now.

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    This is one of the things I don't like about paper documentation. When I worked at a facility that charted on paper, we opened and closed the rings on the chart so many times that it was easy to lose a paper. It would also be easy for "foul play" (i.e. someone intentionally removing pages from the chart). Of course it is not legal to remove and throw away a page from a chart. At this point, I'm not sure there is much you can do other than keep your eyes open and see if there is happening other places. If not, it may have been a honest mistake of losing a page. If so, they it is time to dig deep, ask others if it has happened to them. If it has happened, you can take it to the DON, but it may be time to consider other employment. :sorry:

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    Totally illegal. You should probably consider finding new employment if this happened. Who knows how many other times this has happened. Might want to consider an anonymous call to the state, or jacho whilst finding employment elsewhere.

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