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    Monday, March 21, 2005

    Altering Records: Patterico notes some interesting testimony from the Schiavo case:

    Every time I made a positive entry about any responsiveness of Terri’s, someone would remove it after my shift ended. Michael always demanded to see her chart as soon as he arrived, and would take it in her room with him. I documented Terri’s rehab potential well, writing whole pages about Terri’s responsiveness, but they would always be deleted by the next time I saw her chart. The reason I wrote so much was that everybody else seemed to be afraid to make positive entries for fear of their jobs, but I felt very strongly that a nurse’s job was to accurately record everything we see and hear that bears on a patient’s condition and their family. I upheld the Nurses Practice Act, and if it cost me my job, I was willing to accept that.

    I think it's fair to say that with electronic medical records this kind of thing wouldn't happen. Of course, it's also very difficult to remove a record that's been written in ink, unless it's a solitary entry on a solitary page. Surely, there must have been some gaps in the record if what the nurse says is true.

    UPDATE: A reader sends this link that questions the credibility of the nurse. The court did not find any evidence that the records were altered as substantially as she alleges. The reader also asks, "What would you do if a nurse wrote untruthful things in a patient's chart? How would you correct the record?"

    Sad to say, this does, in fact happen. Especially when a nurse is trying to cover her own butt. It isn't uncommon to find notations in a chart, added after a patient went bad, claiming the nurse tried to contact the doctor earlier than she actually did. It certainly would not be wise to remove the incorrect notation; that smacks of a cover-up. The best approach is to note in your own note the actual time notification occurred. "Nursing note says I was contacted at 2pm but my pager shows page occured at 3pm" for example. Those digital pagers do have their advantages.

    posted by Sydney on 3/21/2005 07:59:00 AM 0 comments


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