Help...How do I protect myself from nurses who tamper with charts

[sfox7]

Hi,
I have been an LPN for 4 years but I have never been faced with this problem before. I went to work and a patient was to have a specific medication which was on the MAR and not in his med drawer. I called my supervisor and we reviewed the MD orders ( this pt was a new admit) to see if the med on the MAR was correct and the MD order stated it was. My supervisor advised me to re-order the med from pharmacy (it was haldol) which I did and administered it as the MAR and MD order stated. This past saturday when I came to work, I was informed by my supervisor that a med error was made because this medication was not supposed to be given. I asked her if she remembered us looking at the MD orders and MAR last week and she stated "so much is going on I just can't remember". When I pulled the chart to show her the MD order, IT HAD BEEN CHANGED TO REFLECT NO HALADOL ORDER. I called pharmacy and they sent me a copy of the order that had been faxed to them which was the one that showed the pt was to have haladol. I would not sign the med error and attached a statement and a copy of the MD order that was originally in the chart to go to the DON. Help I don't know what to do.... Thanks greatly

[AmandaWIRN]

Write this up- if your DON does not help you, report it to the board of nursing. Make sure you keep a copy of the original order as proof.....

I would also look for another job- I wouldn't want to be working with people doing something ILLEGAL like changing charts or modifying doctor's orders....

[JennyP]

Altering charts is both wrong and illegal. Did the doctor change his mind that the patient shouldn't have the Haldol? Was it written on the wrong chart? It doesn't matter; the chart shouldn't have been altered! In either of the above cases, the DOCTOR should have crossed the order out with one line, circled it, written "Error" and initialed it. Anyone who makes an error while charting should do it the same way. No one should alter charts.

My advice is to take this up through the proper channels (this is usually head nurse, supervisor, DON, admin. and CEO -in that order).

It is possible that you may be fired or laid off for being a whistle blower; if so check with your states' Dept. of Labor or the state Attorney General because you do have protection for this. And yes, you can report it to the state and the board of nursing. BUT don't get in trouble yourself for copying a part of a chart for your records: HIPAA infractions are quite serious too.

[cougarnurse]

I agree with hanging on to a copy of the ORIGINAL order! I can't tell you how many times I have seen this cr*p go on. Protect your license is your first concern: find another job.

Keep us posted on how things go.

[JennyP]

I know how much you may want to CYA and keep a copy of the original orders; but it is highly illegal and you could lose your license over it.

HIPAA states that one must "De-Identify" a chart. That is you must do the following:

Removal of These Identifiers* Makes Information De-identified
- Names
- Geographic info (including city and ZIP)
- Elements of dates (except year), ages over 89 years
- Telephone #s
- Fax #s
- E-mail address
- Social Security #
- Medical record, prescription #s
- Health plan beneficiary #s - Account #s
- Certificate/license #s
- VIN and Serial #s, license plate #s
- Device identifiers, serial #s
- Web URLs
- IP address #s
- Biometric identifiers (finger prints)
- Full face, comparable photo images
- Unique identifying #s

*See 45 CFR 164.514(b)(2)(i) for a complete list.
Health information is de-identified if the above identifiers of the individual or of relatives, employers, or household members of the individuals are removed and the covered entity has no actual knowledge that remaining information can be used, alone or in combination with other information, to identify the individual.

So if you insist on keeping a copy of the original orders, all of these things MUST be removed.

I've worked with the BON of MN and also with other entities; we used to do Mock Trials. I've also known nurses who've lost their jobs and been disciplined by the BON for breaches of privacy.

Think long and hard (and even seek advice from a lawyer) before you copy and save part of a medical record.

[cougarnurse]

Jem. of course that's understood; however, remember the NH has the original chart 'forever'.

Had a similar 'case' at the facility I work for: severe head injury secondary to dementia/psych dx. Old DON left, and 'new' DON came in (had returned from LOA). There was chart tampering AFTER the one DON left, and it was proved. Of course, this was over 2 years after the incident. Hard to remember names after 6 months, let alone 2 years, especially if it is not a 'memorable' incident.