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I was written up for falsification of medical records, but I'm not sure what I did was a violation. Can you advise?

Monday November 5, 2012
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Question:

Dear Nancy,

I was written up for falsification of medical records. I pulled lactated ringerís solution from the pharmacy, when normal saline was ordered. My director of nursing says that because I signed off on normal saline on the online medication administration record, and charted normal saline in my progress notes, I falsified the medical record. Is this true?

Corrine



Nancy Brent replies:

Dear Corrine,

There are several issues presented in your question. The first, of course, is the one you raise concerning the falsification of the medical record ó the IV bag that you signed for, hung and documented. The definition of falsification of the medical record that would apply here is your facility's definition of the same. The definition, for example, may not make falsification an intentional act, but may define it as mistakenly and/or accidentally documenting something untrue.

You can review the facility's policy about documentation in medical records and the policy on employee conduct. Either or both may provide you with the facility's definition and what the consequences are when the policy is violated.

Another concern is your medication administration practices. It does not appear that you followed the five rights of medication administration ó right patient, right dose, right time, right route of administration and right medication. Did you check what you signed out and administered before hanging the bag? If your facility uses bar codes for medication administration, did you properly swipe the code and check the IV bag for its identification? The bottom line here is that lactated ringerís is not normal saline. How the error happened is something you might want to review in your own mind, so an error like this does not happen again. This is especially important if there could be serious harm to, or the death of, the patient due to the improper administration of an IV fluid.

If you believe being written up for this situation was wrong, or you were written up for a wrong violation of the employee code or documentation policy, you can grieve the write-up through your employer's grievance policy. Be sure to follow the requirements of the grievance and do so in a timely manner.

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.