"Rewriting" Home-care flow sheets

[billssisbeth]

I have a Documentation Ethics question....

I have been asked multiple times to rewrite signed nurses notes that were perfectly legible... either a water "spot" or stray pen mark was the reason I was asked to "rewrite" it. Nothing was unreadable or omitted.

My employer wanted to destroy the original. I kept them from doing so by saying "see original document" on the signature line of the regenerated note.

I have looked into this per my State Board of Nursing...but there is no definite outline as to whe a Note should be "redone" if soiled, obliterated or marked on AFTER the authorized signature is in place.

Does anyone have ANY ideas about this? And I need resources to back me up....

Thanks.

Beth.

[barefootlady, ADN, RN]

I don't understand. Are you rewriting your own note from a previous day? If so why? Water marks while not neat, should not deter anyone from reading a ledgeable note. Pen marks? Is it a scribble or just a thin line? I would not rewrite anything unless it was doing an additional note to clarify a problem and the solution achieved for that problem.

Please call the board in your state and obtain the information you need and if, as I suspect, they say no notes should be "rewritten" once signed, present this information to your agency, although they already know this I am sure, and do not "rewrite" anything in the future.

We may all write a clarification note or additional note for a certain day if we write something like this: Clarification note for 03/31/05 : Patient was given an extra Lasix 20 mg po by daughter after this nurse left patients home. This nurse had called and reported patients edema, as noted in note of 03/31/05 but was unable to remain in home for return call from physican for further instructions. This RN was informed by office nurse physician was unavailable for 2 hours d/t staff meeting. This RN returned to office and upon return to office was notified by daughter that physician had called and given her instructions. This RN verified these instructions by talking with physician. Signed and dated 04/01/05 @08:30 AM.

Hope this helps, sorry if I am treating this as something new to you, since you probably do this all of the time, but I thought it may help a newbie.

Have a blessed day !

[Private Peds Nurse, LPN]

I do my nursing notes on the computer...that way, they are very legible. My Supervisor loves it, she can read everything. She at first did not want me to do them on the computer, then when I went back to writing, she actually told me to go back to the computer :) Which I was very happy to oblige her!!!!

My notes are much more in detail, since I type much better than I write.

[MissJoRN, RN]

OMG... I do pedi home care and often find myself handing in notes that have been scribbled over with crayon or have juice spilled on them by siblings, LOL. Never have been asked to re-write. Nursing Mag did a little article in their charting feature months or years ago about re-writing and I remember them saying, as you did, to see original entry, never to destroy. They may have this referenced in one of their books?