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One of the physicians in my facility has a practice of documentation that I don't agree with and I don't think it's legal. What should I do?

Wednesday August 21, 2013
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Question:

Dear Nancy,

I am a certified urology RN and I work in a specialty clinic. I do all the intake interviews on new patients and chart my impressions and the information I receive from the patient. The chart then goes to the physician seeing the patient to add his exam notes. One of our physicians informed me that, in some cases instead of adding his note below mine, he is editing or adding to my note, removing my signature and signing his name. When I expressed concern about this, he stated since all my practice is under his supervision, he can legally do this, nurses don't get sued and it is not an issue. When the other RN and I tried to disagree, he stood firm and was not happy. We feel any documentation is legal and cannot be changed and signatures cannot be removed. He disagrees, stating that in the end it is his chart, so he is responsible. Are we wrong on this?

Paul



Nancy Brent replies:

Dear Paul,

Suffice it to say your physician needs to take a course on documentation in the medical record. It is unclear how long this physician has been practicing, but his ideas and beliefs about proper documentation are incorrect and one example of the problems inherent in this type of situation is the potential for falsification of the medical record.

You might want to try and rectify this situation by confidentially sharing these incidents with your chief nursing officer. From the way you have described this physician's response to your concerns, it’s possible only someone in the facility administrative hierarchy will be able to deal with this successfully. Because the physician must comply with the medical bylaws and clinical privilege requirements of the facility, he or she might be more motivated to change his or her ways.

Another individual in the specialty clinic who should be made aware of this conduct is the risk manager. Filling out an incident or occurrence report and speaking with the risk manager directly and confidentially would be another way to let others know about this unacceptable conduct. Because the facility would be at risk should one of these charts be subpoenaed during a professional negligence trial alleging injury or death of the patient, risk management will want this conduct stopped.

The state board of medicine also could be contacted about the physician's conduct, if there is no other option and your facility’s administration refuses to intervene to rectify the situation. If this is the option you decide to exercise, consult with a nurse attorney or attorney in your state who can guide you in reporting this to the medical board.

Regards,
Nancy




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.