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I am aware that the documentation of an incident with a patient who died is inaccurate. What should I do about this?

Friday August 24, 2012
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Dear Nancy,

I was monitoring a patient during a procedure and he died shortly thereafter. This was not a surprise to anyone, as it was expected this might happen. The radiologist performing the procedure told the attending physician that the patient vomited during the procedure and the conclusion was made that a contributing cause of death was aspiration. This was not really what happened. The patient was nauseated, but never vomited. If he had aspirated, he would have gagged, which he did not. He was never sedated — was alert, although short of breath. The attending physician dictated that this contributed to his death. I told him the patient did not vomit, but he told me that if the radiologist told him he did, then that is what he will record in the chart. The ultrasound tech agreed with me that the patient did not vomit and I noted this in the chart. Both of us were with the patient when the doctor was focused on trying to get fluid from his abdomen and not really paying attention to what was happening with the patient's airway. The documentation of this incident is inaccurate. What should I do about this?


Nancy Brent replies:

Dear Carolyn,

It is unknown if the accurate documentation in the patient's chart by you had any positive effect on this situation. It would seem that the documentation agreed upon by you and the tech, and based on factual observations before the patient died, would have been noticed by someone in the facility. If not, and no investigation of the patient's death took place, or no family involvement has occurred (if there is a family), it is important that you share these facts as soon as possible. You should consult with a nurse attorney or an attorney in your state that works with nurses to help guide you through this process in order to protect you and the information you have about this incident.

The attorney may discuss with you sharing the information confidentially with the chief nurse officer and the risk manager. The facility's lawyer should be involved in this meeting also. There are many ramifications of falsifying patient records, especially when a death has occurred — including professional licensure issues, accreditation issues and insurance reimbursement issues.

As a nurse, you have a legal and ethical duty to speak up about unethical or unprofessional conduct, especially when it is witnessed. This is not an easy responsibility, but with the help of your attorney, it can be done. You should be commended for accurately documenting the facts of what occurred, and now you should follow up on this matter.


Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.