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What can a nurse do if a co-worker changes the documentation time in her patient’s medical records?

Question:

Dear Nancy,

I work 3-11 on a 21-bed locked mental health unit. About a month ago I noticed two of my nurses notes, time of documentation were changed from 1745 to 1445 and 1700 to 1400. I also noticed the same person had written under my note both times. I reported it to my nurse manager and the person was questioned by a human resources staff member. The person denied changing any times. This person has not spoken to me since this happened. I now cross out the rest of the page after I finish documenting, even if more than half the page is blank. This is really bothering me.

Mary Sue

Dear Nancy replies:

Dear Mary Sue,

It’s unclear what would be the motivation for this co-worker to change your documentation, but it is of concern. You were right to report it to your nurse manager and to HR. It might be important to take this concern further up the administrative chain and notify your CNO of the problem. The CNO should be aware of this problem, and the CNO can confidentially share the information with the CMO and others who need to know about this person’s behavior.

Especially important to share with the CNO is the conduct of this individual. Not talking to you may not bother you personally, but there may be a need at some point — and there probably will be based on the fact you are on a mental health unit on second shift — for communication between the two of you concerning patient care, patient behavior, pharmacy issues and so forth. This behavior is troubling at the very least.

It seems strange no action was taken by HR or your nurse manager about the documentation issue. The employer must have a policy concerning documentation in the medical record and prohibitions against changing documentation without following the proper protocol as outlined by the employer in the policy. That, coupled with the individual’s decision not to talk to you, should move HR and the nurse manager to require this staff member to change the person’s conduct or be disciplined.

It is a wise idea never to leave blank spaces in your documentation and the lining out or crossing out of lines after you document from here on in is a wise idea. Although it does waste paper, in this instance it is necessary so this person is not tempted to continue adding something under your documentation and not take accountability for it. You will also need to check your documentation regularly, and if any additional alterations occur, immediately notify your nurse manager and HR of the alterations.

Regards,
Nancy

By | 2014-10-20T00:00:00-04:00 October 20th, 2014|Categories: Blogs, Nursing careers and jobs|0 Comments

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