I work in a hospital that uses electronic documentation. Once assigned a group of patients, a nurse has a work queue, which shows all of the documentation that needs to be completed for a patient. Some charge nurses and my nurse manager often assign themselves to the patients and then cancel or reschedule certain pieces of documentation. My nurse manager has even been known to do this from home. This greatly concerns a number of nurses on the unit who feel this practice
Dear Nancy replies:
Without more detail, the practice of canceling or rescheduling certain pieces of documentation by some charge nurses and the nurse manager sounds a little odd. What are the reasons for canceling or rescheduling the documentation? What is substituted for the canceled or rescheduled documentation? Who does the substitutions? How does it appear in the patient record (e.g., addition to note)?
As you know, accurate, complete and timely documentation of patient care is essential both legally and ethically. Changing documentation in any way that alters the original note such as re-writing an entry;, altering an entry without clear notations as to who did the alteration, when it was done, and why; and adding to an entry at a later time without the proper date is falsification of the patient record. Falsification of a patient record can lead to criminal liability, liability under Medicare and other insurance plans and discipline by the state board of nursing.
Electronic documentation usually has audit trails that indicate alterations in a patient record and by whom it was altered. This provides ready proof of alterations and, at the same time, clearly points to those who have done the changes. In this instance, there may be both an audit trail of the charge nurse and nurse manager directions and the specific staff members who have done the changes.
A group of your staff may want to consult with a nurse attorney or other attorney in your state who works with nurse employees and understands nursing informatics. You and your fellow colleagues might be placing yourselves in harm’s way by re-doing patient notations if not done honestly and consistent with documentation principles.