I was recently terminated from a nursing job for a charting error. to make a long story short I went back into a chart the day after to fix something in my charting in a patients chart. I deleted a piece of charting because i said i did something without actually doing it and wanted to make my charting correct. unfortunately in retrospect my company brought it to my attention that this is a breach in HIPAA thus terminated my employment.
This has been particularly hard for me to face as i am one of those people who is a perfectionist and always plays by the book. I have about 2 years of nursing experience (1 year night shift on a step down unit -was a zombie and bullied by a nurse, now 1 year office nursing/ambulatory surgery) and am now so frustrated and so upset with myself. All i can do is sit here and cry because I am so mad at myself. I just feel like i have a bitter taste in my mouth about nursing now. I used to be this young intelligent nurse so excited for my career to begin and had such high prospects.
I feel that I have lost all my confidence and feeling like a failure. Who will hire me now?
Any suggestions from people in similar situations and how to move on? should i quit nursing or keep looking for a better fit?
Medical records are a legal document. Any changes made (in writing), are to be done with a SINGLE line drawn through it, initials and date above or beside it. It's 101 in biz and medicine that deleting anything is a no no!! It leaves things wide open. What if there was a law suit? Think about it...
How was the OP supposed to "draw a line through it, initial and date".. on an EMR?
Does your BON have employer mandatory reporting when an employee is terminated for cause? If so, suggest you to seek legal advice. You will be advised that is not in your best interest to discuss details of the termination in public.
I was not trying to discuss the reasoning of my termination or to get an legal information all mixed up. I know mistake and that it was just that, a mistake. I am beating myself up every day. I am a young nurse who is still learning. I was looking for help on how to get passed this and to move on.
Been, there done that, not sure what I've done to offend you, but is it necessary to be so rude?
I could think of many other (less offensive) ways to phrase your question.
The EMR system I currently work with doesn't allow a "delete". And why can't I state how to properly correct a legal doc? Even in EMRs you can correct or ammend showing initials and dates.
OP, part of learning from your mistake is to take the information offered and keep it for the future if needed. Stop beating yourself up, it won't do you any good.
If you're worried about what you'll say to a future employer or what your previous employer will say... I suggest you apply for positions you don't have your heart set on and get and see how that goes.
See if you can get any letters of recommendations from anyone, and think of how to respond to an interviewer when asked about your last position. It won't be easy, but you can do it if you find a way to state what you did here in a professional, caring way.
A correction is a change in the information meant to clarify inaccuracies after the original electronic document has been signed or rendered complete.
Late Entries
A late entry only applies to documentation within the EHR that is entered after the point of care.
Retractions (see also Deletions)
A retraction is the action of correcting information that was incorrect, invalid or made in error, by preventing display or hiding the entry or documentation from future general views.
Once a report has been signed, it should be locked from any future editing. An addendum is new documentation used to add information to an original entry. Addendums should be timely and bear the current date and reason for the additional information being added to the health record. Late entry should be noted for all documentation added to the chart when entered next day or later post the date of original entry.
Retractions should be made in the source system or where the documentation was originally created. Usually only HIM staff have permission to annotate record, documenting issue + make entry hidden from viewing. This information should still be available in the background, but will not display in the regular record view or be released upon request for the record. It is important to consider that while this information may be in the "background" of the electronic heath record, it should not be reproduced on any printed versions of the record.
Documentation standards are covered under HIPAA Security regulations which requires facilities to educate all employees on facilities EMR policies. Information on how facility handles correction of EMR entries SHOULD be mandatory education as part of orientation/onboarding employee.
You can survive this by telling future employer what you have learned from experience: read article on documenting in an electronic medical record, completed continuing education course e.g. Document It Right: A Nurse's Guide to Charting or attended informatics nursing in-service/meeting.
I did not get the impression that OP was working off the clock...
It is a HIPAA violation to access any patient record that you are not assigned to in a care capacity. IE Clocking out and continuing to chart is violation because since you are technically not working your legal access to the chart is void.
Been, there done that, not sure what I've done to offend you, but is it necessary to be so rude?
I could think of many other (less offensive) ways to phrase your question.
The EMR system I currently work with doesn't allow a "delete". And why can't I state how to properly correct a legal doc? Even in EMRs you can correct or ammend showing initials and dates.
Rude is subjective. I am not on this site to be "less offensive" to non professionals who feel they can comment on a professional issue. OP is concerned about her PROFESSIONAL charting. A CNA has no concern regarding a professionals charting, as they have NO license to lose.
Been, there done that, not sure what I've done to offend you, but is it necessary to be so rude?
I could think of many other (less offensive) ways to phrase your question.
The EMR system I currently work with doesn't allow a "delete". And why can't I state how to properly correct a legal doc? Even in EMRs you can correct or ammend showing initials and dates.
I didn't think she was being rude. I think she was asking a question. What you read into is on you.
Specializes in Psych, Addictions, SOL (Student of Life).
How was the OP supposed to "draw a line through it, initial and date".. on an EMR?
in our EMR System called Point Click Care there is a strike out feature which actually draws a line through the item in question and has a box for a brief explanation with your electronic signature only the original writer or an administrator can do a strike out on our system.
Been there,done that, ASN, RN
7,241 Posts
How was the OP supposed to "draw a line through it, initial and date".. on an EMR?