Another nurse is editing my chart documentation. Is this a form of harassment? Is it legal?

By | 2022-02-15T17:45:27-05:00 December 20th, 2011|1 Comment

Question:

Dear Donna,

I work on the day shift for the Department of Corrections. The evening RN has been reviewing charts that include my documentation and is actually adding items that she feels should be included. I have spoken to my nurse administrator, who sees nothing wrong with this. I find this “editing” demeaning, and it makes me look incompetent.

I am well-qualified and have quite satisfactory evaluations from my manager. I feel this is harassment and I would like it to stop. Do you think this is a form of harassment? I obviously do not have support from my manager on this issue.

RML

Dear Donna replies:

Dear RML,

It’s always challenging for me to respond to a situation like this without knowing all the specific details. Generally speaking, altering a medical record, especially when one person alters or adds to another person’s charting, is both illegal and unethical.

Your facility/employer should have written policies and procedures on charting and record keeping that should be followed. Additional guidelines also can be established to help caregivers maximize their documentation at the time of creating the record. But it is never OK for someone to go back in and amend the record afterwards, regardless of their position or background.

It doesn’t sound like a case of harassment, but the issue does need to be addressed and stopped if someone is altering or amending your charting. A simple Internet search for “altering a medical record” will provide plenty of background information for you to speak to your manager about this. In the meantime, keep notes to track what has been done and said, what actions you are taking and what the response is. Be proactive and assertive to get the situation resolved.

Best wishes,
Donna

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One Comment

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    Mary K Tashlin April 18, 2021 at 1:56 pm - Reply

    I have a question, I just started at a doctor’s office and I am not allowed to chart. I am to verbally tell her and she makes it, I feel very uncomfortable with office manager making my notes when I give injection or treatment to a patient. I’m not even allowed to be on the emr or have the paper chart( old doc he still has papper charts) that I’m not allowed to document in. I feel I could be set up here.

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