I am an OR nurse manager in an ambulatory surgery center. An RN recently was fired from the center and rightfully so by our administrator, who is not an RN or clinical person. She asked me what to do about the fired RNs unsigned nursing notes. The RNs lack of documentation and unsigned nursing notes are only the tip of the iceberg, and I do not believe it would be prudent to call him back post-firing to sign off on his notes. May we sign off as employee terminated signature on file in this case? How should healthcare providers handle unsigned or unauthenticated charts by a now-fired employee?
Nancy Brent replies:
Suffice it to say that in the situation described in your question, there is little that can be done to correct the problems in the medical records of the terminated employee. Although the problems are serious, the way to handle this type of situation is to have a policy and procedure in effect in the facility that regularly monitors patient care entries and requires those healthcare providers who are deficient in their documentation to correct the problems identified. Many such policies and procedures also include discipline of the healthcare provider who ignores any request to complete his or her documentation in a timely manner.
Corrections, additions to an entry, an entrys authentication or a late entry, as examples, need to be handled pursuant to the facility’s adopted policies. For example, a late entry must be identified as such while entering the current date and time. An addition to an entry must also reflect the current date and time, be identified as an addendum and be done as soon as possible after the original entry was completed.
Before doing anything with the charts in question, you and youre administrator should discuss this issue with your risk management department and the facility attorney. Although there may be little that can be done with this particular situation, it might spur the facility either to adopt a policy requiring regular monitoring of patient records or strengthen the one already in existence.
A facility that does not insist on timely and complete documentation and does not monitor records regularly during the course of a patients stay faces serious sanctions if an accrediting agency, such as the Joint Commission, a state licensing agency or a federal surveyor visit from Medicare/Medicaid discovers incomplete patient care records. Moreover, the individual healthcare provider who has not fulfilled his or her duty to document patient care as required by legal and ethical professional standards also faces potential disciplinary action by the state board that licenses that healthcare provider.