I work at a day program for disabled adults and recently was asked to rewrite a narrative on an incident. Is it legal to ask an RN to rewrite such a report?
Wednesday January 20, 2010
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I am the only nurse at a day program for severely disabled adults. Recently, one of the people we serve arrived at the program “sound asleep.” I was not notified of this condition until 11:30 am when staff was unable to awake her for lunch. I found her non-responsive, with normal vital signs, pupils equal and reactive, skin warm, dry and pale. Her arms were flaccid. She is a diabetic and usually is alert and observant of activities around her. She was not showing signs or symptoms of either hyperglycemia or hypoglycemia.
Upon questioning the staff, I found out the bus driver stated she was in this condition when he picked her up at her group home. Since her condition had not changed, I notified her house manager who notified the house nurse. They requested she be sent to the ER for further evaluation. The paramedics tested her blood sugar level and found it to be at 180. The young lady finally woke up 12 hours later with no definitive explanation as to why she stayed in that non-responsive state. She stayed in the hospital overnight and returned to her home the following afternoon, and to the day program two days after the incident.
When I wrote up the narrative on what happened, I used the words non-responsive and flaccid to describe her condition with the statement that her vital signs were normal at 20-minute checks. My supervisor, not a nurse, had me remove any reference to her being non-responsive, and replace it with “sleepy” or “sleeping.” I was not allowed to mention that she had come to our program in this condition, nor that she had been in this condition for two and a half hours before I was notified.
I am concerned this makes me look like I am a totally incompetent nurse and puts me at risk the next time anything of this nature happens. Is it legal to have an RN rewrite a narrative of an incident and downplay every aspect of the situation?
Ted
It is fairly certain that you know the answer to the question you raised in your submitted question. But, just to emphasize the legal principles involved, it is not legally acceptable to rewrite a narrative or downplay every aspect, indeed one aspect, of a patient situation. One’s obligation as a nurse is to document accurately and honestly in the patient record any and all care provided to a patient, including the results of a patient assessment. The terms you used were medical/nursing terms based on your observations as an educated and skilled nurse. There is a difference between “non-responsive” and “sleeping” and flaccid is a specific term that has a specific meaning in the healthcare arena.
Under certain circumstances, a nursing entry can be rewritten. For example, if a chart entry is damaged because of a coffee or water spill on the page, or the page is torn in some manner, facility policy may allow a rewrite with exactly the same information (as it can be reconstructed, if need be) and with the damaged page included in the patient's medical record. The reason for the rewrite, along with the date of the rewrite and time, also should be included in the entry. Additionally, sound practice suggests that risk management be notified of this incident, so there is no surprise if the department or the chart is requested by the patient or the family or it is subpoenaed because of a pending filed case.
Rewriting an entry inconsistent with sound legal principles can result not only in casting doubt on the credibility of the author of the entry (e.g., what is the author trying to hide?) but also is a violation of a state nurse practice act. Falsification of any document that is connected with one's practice of nursing, including but not limited to nursing entries in the medical record, is a basis upon which the state board of nursing can take disciplinary action against the nurse licensee.
Last, but by no means least, the practice of one's nursing profession cannot be limited or dictated to by any other person, especially when the individual is requiring a nurse to do something contrary to the nurse's legal and ethical mandates. Moreover, the suggestions given in this situation potentially place you and the facility at an even greater legal risk than if the incident were handled and documented honestly.
Although there may be a question about why the individual's condition was not picked up earlier and why you were not notified sooner of the situation, once you were notified, you did what you could do to get the individual the evaluation and care she needed.
Cordially,
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.
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