Tell me if this would be legal

[catlynLPN]

Ok, here are the circumstances. This is long, so bear with me.

We have this computer system where I work to give medications by.

Everything {meds} are charted in the computer.

This computer still has glitches and bugs in it.

So......I am a PM nurse. I NEVER work days.

So, one evening, a co-worker and I were checking on some things and ACCIDENTALLY found that the computer had placed MY initials into the early morning medication round......just as if I had given those early morning meds but I did NOT. Something is wrong with the computer......I reported it to our new DON, who has been on the job now about 2 weeks and they are going to try to fix it.

The day in question was April 4th, on the early morning med pass.

The QUESTION I have is this.............an employee who works there, came in tonight and was asking me some questions about how this computer works. I was explaining it to her, and I also told her about the computer error where it had put my initials in the the early morning med pass.

She thinks that the new DON can legally cross out my initials, {on the printed MAR destined to be placed in the charts} date it, {just like you do to correct an error} and then write in the nurse's initials that the computer SHOULD have placed there. {The nurse whose initials should be there has retired...no longer working there.}

I told her that was ILLEGAL. She argued with me and said it is legal. She says she has been correcting errors for people in the charts and dating the error, for many years {she gives an example of a misspelled word}.

I told her correcting a misspelled word is one thing, but in charting medications, that is illegal for a third nurse to cross out one nurse's initials and write in another nurse's initials. She says it is legal and that our new DON could do it.

What say you all??? Would you think it would be legal for the NEW director of nurses to do that on a date when she wasn't even yet employeed there.....{the date is secondary....just the act of crossing one nurse's initials out and writing in another's....is a case by itself.}

Sorry for the long post.

[RNsRWe, ASN, RN]

I think that this can best be answered by your facility's legal department! If it were me, I'd start there. People here can give their opinions, but none is a legal avenue for you to follow.

[catlynLPN]

I think that this can best be answered by your facility's legal department! If it were me, I'd start there. People here can give their opinions, but none is a legal avenue for you to follow.

Well, I wasn't asking for advice to FOLLOW....just OPINIONS on the possible legality or illegality of the situation.

I REALLY think that someone is going to have to correct it, but I don't know who that will be.

[justme1972]

I would say legal.

Bottom line, the chart needs to be correct. A nurse who is no longer a employee CANNOT make the correction, and a person in management, who has direct knowledge that the chart is wrong, if it is impossible for the original nurse to correct it, I say the DON has the authority to correct it PROVIDED there is a note placed on why the change was made.

Think about it: How would you like it if your initials appeared on a chart in error, you quit your job, and then a lawsuit came up and everyone know that you didn't give the meds but everyone said, "Oh, but we can't fix the chart".

How would that make you feel?

Now, if it was just random supervisors and charges making these changes, then that is a different story...but since it's the DON with direct knowledge...I don't see how making a correction is wrong, because again, bottom line, the chargt is NOT reflecting what happened accurately.

PS: Be very, very careful about quoting to "upper management" what is legal and illegal...that can be a career-killer. Unless it's a chart you are directly responsible for...the DON (if wrong) is putting her own butt on the line and that has nothing to do with you unless you see direct harm to a patient.

[queenjean]

In our computer system, I (a lowly staff nurse) can chart that someone else gave a med. I cannot unchart, though.

Our system always shows who did the charting, changing, etc. So even if *I* chart that someone else gave a med, it also shows my name with the documentation. It really creates a huge trail. I wonder if your system is the same--it reflects the changes that she makes, but also shows who made the changes.

[bollweevil]

It sounds so utterly ridiculous, all of it. It is a good argument for doing things by hand, the old fashioned way.

I can't possibly answer your question but my first impression is that it sounds wrong for the DON or anyone else to be altering someone else's charting. As for your initials being present incorrectly, you need to make sure that gets corrected STAT. And keep good time records, showing you were not on Days then.

[ceecel.dee, MSN, RN]

Well, it must be fixed, and if not by anyone at all, then how does it happen?

It seems to me that the DON, since that is who you talked to about it, should make the change along with the requisit explaination and her signature.

[Nightbloom]

Its legal. If it the initials were initially wrong and they are simply correcting with the correct initials, then it is legal.

I shouldn't be giving legal advice.... but I am a licensed attorney in Kentucky and I do believe that its legal to do that.

[ann945n, RN]

I would say that the DON could cross out your initials and then write a note (not the other nurses initials) explaining who gave the meds and what happend. I do not see anything illegal about that.

[pagandeva2000, LPN]

I think that the DON can make a correction as well, as long as she has the correct knowledge of what happened. I agree, if the mistake remained, you would be liable, and would probably like to see somewhere that a correction was made. If this chart showed up in court, then, the DON would have to explain and at least your story would correlate to why this happened.

[catlynLPN]

Ok, thanks to all who replied. I can see now, that it could and should be corrected by the DON, for those med sheets to reflect the truth.

I was NOT on dayshift, only time I've worked days is that I have come in at 10 am to help with the NOON med round, twice in the last two weeks. {We're severely short staffed right now}.

The way our shifts are and the lengths of our shifts I wouldn't be able to get there for the early med round.

ANYway, my TIME card shows when I've been on duty.

I will ask today to see if the DON will correct it.

If nothing else, I can print out all those sheets myself that can be destined for the charts and cross out my own initials and let management decide what they want to do about the other nurse's initials not being on there. Or they can write in an explanation of why.

The computer needs to be fixed so that it doesn't do this again.

The programmers who are responsible for this system are going to have to do something.

This could be a dangerous situation. People's initials getting in spots where the person didn't even give meds. If this computer system is that unreliable........who needs a system like that?

No telling how many other times this may have happened.

[Jolie, BSN]

My question is why did "the computer" put your initials in for the wrong shift? Aren't you required to log into the system to chart, which would identify you as the person doing the charting and automatically enter your initials?

Is someone else using your log-in ID?