is re charting legal

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one of my unit managers often requests that we rechart...that is, that a whole page of hand written nursing notes is distroyed and we re chart the page to make it include something that was not in an original chart entry. is this an ethical/legal practice. she will have the original nurses copy the original notes ...then add something she thinks was not clear or missing in an entry rather than having a late entry or addendum. notes that do not directly pretain to the entry to be altered are coppied as they originaly were. I work in long term care/ rehab .

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Specializes in pure and simple psych.

All the courses I have had on charting, or legal issues would say NEVER destroy a medical record. If she wants to edit them first, then she should ask people to write out the rough draft on a scratchpad. Then both should sign it, if she edits content. The olny time recopying is allowed is when the original is ruined, ie, coffee spill washes out part of the note. Then the original stays in the chart, and a copy made, with the notation that it is copied for legibility.

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I agree with Sanctuary on the rough draft. I am a student nurse, and we are all provided with special sheets from our instructors that we use to jot down our notes during our clinicals. At the end of the day, our notes are reviewed by the instructor and modified if necessary BEFORE we write them in the patient's permanent record. These sheets are only for our personal use as we are still learning how to properly chart information. Under no circumstance are we to destroy ANY part of the patient's record. If something was mistakenly documented or omitted, then it must be noted as an addendum to the original note.

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your boss sounds pretty anal. While it is not legal to do this, it goes on all of the time and there is no way to tell if it was the original or not when it is looked over later.

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Specializes in Trauma ICU, MICU/SICU.

Definitely illegal! Refuse and tell her to write an addendum/late entry. She's making it appear that something was charted earlier when it wasn't. She could easily manipulate something to appear to have happened been noted earlier than it was actually discovered. I would want no part of that. It is YOUR license. She obviously will not back you up if her "re-charting" creates a problem for you or others. She is already showing what a dishonest person she is.

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Not only is it illegal, but I have never heard of anyone doing this. I agree with the above poster, she's a dishonest person.

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If you forget something...how about a "late entry" note. There isn't enough time in a 12 hours shift as it is...how does she expect you to rewrite?

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Specializes in Critical Care.

It's an illegal destruction and illegal alteration of a record. If a Court ever found out about this, it would completely destroy your credibility, not just in this case, but because legal cases are public records, in EVERY case you might ever be in thereafter.

(and that IS possible for defense attys to discover this due to the fact that sometimes such changes are enough to make that entry just not 'jibe' with the rest of the record, leading an atty to ponder to you in a deposition why that is the case. At that point, the illegal charting is either discovered, or you are forced to perjure yourself.)

And don't doubt that defense attys have experts looking over charts to discover EXACTLY this kind of illegal alteration.

~faith,

Timothy.

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Specializes in MR Peds, geris, psych, DON,ADON,SSD.

Don't, Don't, Don't do it. This is falsification of documentation. YOU not your supervisor can lose your privleges to practice. Because you know it's your word against hers when YOU get caught. I personally would go to my Administration/DON and report this. Scratch pads are a bad idea because it it's lying around when STATE comes in it's "fair game" to read. What about a 24 hour report sheet to put your "thoughts" down on and chart from it?

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Specializes in MICU.

Illegal.

Once, we had a doctor look up from a chart, confused, and say, "Did Mr. xxx in room die last night?!?!" Well, no. He's still there right now. "Well, a nurse wrote down a whole death note in here."

Oops! Wrong chart. and that wasn't taken out. Just crossed out with with a notation of "wrong chart documented, xx".

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Specializes in ICU/CCU, Peds, DD's, Hospice.

bad!!! bad nurse!!! have no part of this nurses evil practices!!! always ask yourself what we learned in nursing school..."what would any prudent nurse do?" will it hold up in court should be in the recesses of your mind. our rn is a noble privilage and hard earned calling.

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I've only completed my first quarter in a nursing program and know that recharting is illegal. Medical records are considered legal documents and the signature at the end of the charting is held accountable. I agree with the previous posts; don't rechart and bring this to the attention of higher administration. At some point, can you tell the pt's doctor about this practice?

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