Removal of info from charts

[pedspnp]

I thought it was illegal to remove pt notes etcr from a pts chart. The reasoning am asking is that one of my pt's had lab results from the nursury that tested positive on a tox screen and billing called today needing a progress note that addressed the tox screen, I gave the chart to the md who had seen the pt in the nursery, then mysteriously the lab report came up missing, this was after the md threw a fit and told me that I needed to do the progress note since I was the last person to see the pt but I had never seen the pt in the nursery

[CRF250Xpert]

LOL. I'm just the kind of person that would go back to the computer and print out a new one and pop it back in the chart since the original got "misplaced". Deleting stuff you don't like from a chart is sort of - - well, illegal. That's why I never order a test I don't want, don't know what to do with the result, or don't want to know the result.

[pedspnp]

This report came directly from the hospital so I guess I will just call them and have them send me another copy

[Bonosgrrl]

I would call and have them send another copy.

it may just be misfiled, and ended up in another chart, I have seen this happen many times, it is frustrating.

[pedspnp]

i plan on calling over to the hospital in the morning and ask them to please fax a copy of the lab report, it is just strange that it was in there one minute and when the office manager went to look at the chart after i told her about the issue of a progress note being done and him telling me i needed to do since I was the last person to see the pt.

[caliotter3]

There was once a juicy bit of info about a resident in the chart one time and the nurses started a gossip fest. The juicy info got pulled from the chart. That was not the only time I noticed this happen in a LTC facility.