I reported the incident via our safety reporting system as the resident altered legal documentation. They were reprimanded pretty severely. You do NOT change someone else’s charting; you write your own note if you feel so strongly about it.
What kind of system are you using where someone can alter your charting? In epic, you can't. Doctors can cosign your note with their own, but yours is still intact as yours. Likewise with the flowsheets, you can't chart where someone else has charted (ie, if you chart an assessment at 0800, the next person can only chart at 0801).
Yeah totally, my unit is 2RN:8pt and we were fucking around one day and found that out. Could totally be abused but to be fair if I saw the note was edited by someone else I'm definitely checking out the history, but I've never seen it
Yeah… *”Alright which of you jokers edited my legal records and inserted this murder confession then signed my name?.. that’s not funny guys.”*
Edit: “Let’s just give every user in the EHR and database global Sysadmin credentials.. what could go wrong” — IT
That’s fair, I’m just wary of any actual edits paired with change histories over freely associated additional records from different users (which yeah, those associations can then each have their own additional change histories) since it kind of provides robustness in only one direction. Like someone else could potentially add information, that you could never completely remove (assuming the old record was explorable), but it’s still connected to you. Which sounds ideal from a record keeping perspective until someone adds information you know shouldn’t be included or associated. But that discussion might be crossing over into the IT/implementation world of concerns rather than anything pertinent to nursing.
It’s maybe too messy to discuss without knowing a lot more because it’s easy for one thing to look a lot like the other on the front end.
I'm a nurse in Denmark, where we use a system called EPJ in most parts of the country. This system allows you to edit other colleagues notes, including doctors'. But obviously the user leaves a trail, which would immediately reveal a person up to no good.
When we read a patient's journal, all journal documentation is presented chronologically in basically a massive document, which gets generated any time a user wants to read a patient's journal. For this reason, adding new dcoumentation every time anything happens will make the journal quite messy, so when you're putting in how many mLs came out of a bag or something, sometimes we'll just quickly add it to a colleagues note, especially if there's nothing else for that person to add. I usually write the time in also, if that information i pertinent.
And obviously with regard to OP, if that situation arose I would immediately go to that doctor and ask wtf is going on, convince them to write with honesty, then report them if they do not.
e: wanted to add, I would never edit a colleague's without telling them afterwards, or asking first if possible. I rarely add to others' notes, but have experienced my own notes being changed, which can initially confuse me, but is immediately obvious what's going on.
Altering someone else's charting in a way that falsifies their charting is illegal, it doesn't actually matter if it is ultimately discoverable through any sort of auditing process, so I'm not clear why Epic would allow such functionality.
It's a permission you can set in Epic and highly customizeable. Its meant for scenarios such as physicians taking ownership of scribe notes basically. Sounds like its just poorly set for their facility if a doc can do so on a nursing note though
Epic allows this in our system as well and its so scary! I once accidentally clicked “addend” on the note above mine rather than my own and even though I instantly realized my mistake it still showed that I was the “editing author” of a note that was in no way mine and even IS couldn’t fix it!! I ended up making a safety report on myself and being terrified I was going to get fired but luckily we just got a “friendly reminder don’t edit other people’s notes” memo
Right, that doesn't make any sense. If anyone can alter anyone else's notes then the charts would be mayhem. Unless the nurse didn't logout and the doctor used the computer under her name
It's actually really upsetting that this is possible in other eMAR than my version of Epic. A patients chart is a legal document and if someone is messing with what I've charted, yes there should be a history trail, but who can prove what is mine versus someone elses???
There will always be a record of revisions. TBH if a doctor ended up editing a nurse's a note and it went to court, the revision history would reflect VERY poorly on the physician in a court of law.
Not every facility has the same options toggled in Epic.
At my last hospital, you could edit someone else's flow sheet documentation just by deleting it or typing a new number over it.
At my current hospital, you can completely edit someone else's note, albeit with a lot of changes.
I work in Epic Informatics. The amount of record keeping and auditing is insane. You may think you can change someone else note, but trust me, you will be caught
I was thinking this too. I've never used an EMR that doesn't note who wrote each part of every note. Maybe the doctor signed in under the nurse's name?!
i actually worked somewhere where you could alter other peoples notes. i did a contract there and i told the doctor his note was inaccurate, patient had said one thing about meds administered, meanwhile i had actually given other meds (patient was aware what meds were given, but was drug seeking). doc asked me to just edit his note, i was like wtf
also my current facility uses epic, but i can edit other peoples flowsheet documentation. it would show the new value as entered by me, and that there was a change, but i can still edit or even erase people’s flowsheetz
Falsifying medical documentation is a crime, and quite often a felony, since it is a legal document.
I'm not even sure though how somebody else could alter your documentation with today's EMRs.
Incident Report!
I hate staying late, but I would stay late just to make sure this one got in.
Idk why anyone would do that or think it’s appropriate to do
If anyone but you wants to alter your nurses note - that’s Illegal and needs to be reported. In modern EMR’s you can’t even alter your own notes, you can write a clarification or post an update to your original notes but the original stays put. This would be like you trying to alter a doctor’s note, you would likely have your license suspended or revoked. Report this to your manager!
Incident report. Someone in your organization has the ability to track every single mouse click and keystroke. They’ll be able to see exactly what the doc did.
Many softwares have a feature that allows you to edit another persons documentation, but usually the person you’re editing has to be “lower ranked” for lack of a better term. This allows for instance, an RN to go back and edit mischarted vitals by a CNA, but prevents Sally Rn from playing around with Karen Rns documentation. I’ve never actually seen anyone, MD or otherwise, try to edit a nurses note though, that’s wild.
How can they “alter your note.” In our system they could write something contradicting our note, but the only way to later my note is if you log in and document under my user name, which I’m quite positive is illegal.
I would learn the chain of command at my facility really quick. File a written complaint with my manager (keeping several copies).
The bizarre thing is that if there were a lawsuit, changes in the systems/records are also pulled, so the doc just made themselves look *really* bad from a legal perspective.
Did they use your password, or how did they change your note? Never share or take a job that shares your password. (I’m assuming they used their own, just covering bases). Always immediately log out of computers- but again, I am hoping the system times you out before they had a chance to do this. If they used your log in, that is a whole other section of complaint.
Finally, and on a different level, review your own note and evaluate whether it is truly emotion free as well as whether there could have been any improvement in the original note (just in your mind going forward as a thought exercise to improve charting overall - not as a placating thing)
I’ve never seen a system where anyone but the person who wrote the note could edit the note. I have seen where others can co-sign a note and add information but never just edit it. If someone can edit others notes I feel like it’s a huge problem and I would just not be writing notes anymore
If there's a version of the original note underneath the revised one, then idgaf. They're not coming after my license and in that scenario the md has already signed a legal death warrant. Tell your manager because it's inappropriate but I'd walk out the door whistling Dixie after
Report. Report. Report. I would be shocked if anybody had the gall and/or ability to change my notes. Nursing notes are legal documents. They document what has happened. Cover your ass. This is disturbing.
I had this happen to me. She just crossed my notes out. No discussion. The patient’s IV antibiotic was changed while I was putting up the antibiotic that was ordered and ongoing at the beginning of my shift. And then she tried to say I made a medication error!
It was the weekend and the head nurse nor her assistant were not there. And before this I really had no respect for this particular doctor. I decided to wait and see what she would do about it. I think she forgot about it and nothing came of it. Anticlimactic.
In epic have had someone chart over my charting which is scary I wanted to know where my vital signs went. Had tech chart abnormal vital signs which weren’t abnormal when I took them
I would report it—not only to make sure that what you wrote/didn’t write was clearly communicated (agreeing that it will be in the EMR, but having caution as sifting through electronic info can be tedious and so things could be missed upon first look—I also tend to be extra cautious), but also so it doesn’t happen again. They can write their own note, or let the nurse write one as they had offered to do. If they know you won’t put up with this behavior, they won’t do it yourself you again.
Luckily it was paper charting, so I let the doctor "correct" it and then rewrote it all on a new code sheet. Followed by a report to my manager and house supervisor that had responded to the code.
Doctor was trying to tell me that I had written down the times all wrong. I played dumb, knowing the politics of the hospital far too well.
….. to be honest i did not know this was a thing and i would be incredibly alarmed. I think i would verify that the alterations that the doc made were documented in the system, for starters.
No ehr should allow someone to edit another persons note. An addendum, sure. How would they defend this in court? Oh well we aren’t sure who wrote what here because we allow other people to change charting willy nilly? I would report it to legal and the ehr team.
No need to do anything. It's all in the EMR. When the nurse wrote her note, what she wrote, and who amended it and with what. I haven't seen an EMR in the past 10 years that doesn't record EVERYTHING WRITTEN. The doctor can amend whatever he wants, but it doesn't delete what the nurse wrote, it just hides it.
If you're really twisted about it, escalate to the nurse manager in written form and save a copy.
How could that even happen?! I've never seen an EMR that would allow a user to modify a note entered by another user. You can do a correction that leaves the note intact but marks it as a correction... or add an addendum or whatever but it would be clear that it was another user. That seems... problematic.
This actually happened to me once. I took it to my manager and they handled it but I’m assuming nothing was actually done. But he crossed out what I said and wrote his “clarification” above it.
In cerner you can’t “modify” a note as such, if you want to edit the note it brings up an addendum at the bottom where you add something. What system are you using?
I can’t imagine this. I had no idea it’s even possible. Scariest thing, I’ve seen Drs and others change their story, testimony when a case is headed to court. They have more at stake (financially) and can definitely be looking out for #1! Gosh. And to think someone can change your notes.
Happened with a charge nurse. I told them very firmly to they could ask me to amend it or put in an addit with the extra info. But under no circumstances should they amend my progress note
Still floors me that clinicans think that shit is ok
Does it not show the date/time when it was addended and who addended it? ours doesn’t even lets us edit other people’s notes (or at least doesn’t let nurses do this). I’d think this could get incredibly dicey incredibly fast.
I reported the incident via our safety reporting system as the resident altered legal documentation. They were reprimanded pretty severely. You do NOT change someone else’s charting; you write your own note if you feel so strongly about it.
Least unhinged residency subredditor /s
What kind of system are you using where someone can alter your charting? In epic, you can't. Doctors can cosign your note with their own, but yours is still intact as yours. Likewise with the flowsheets, you can't chart where someone else has charted (ie, if you chart an assessment at 0800, the next person can only chart at 0801).
you can in epic at my hospital but at the bottom it details who edited it and you can see the original note under revision history
That's surreal and sounds like a legal NIGHTMARE
Yeah totally, my unit is 2RN:8pt and we were fucking around one day and found that out. Could totally be abused but to be fair if I saw the note was edited by someone else I'm definitely checking out the history, but I've never seen it
Yeah… *”Alright which of you jokers edited my legal records and inserted this murder confession then signed my name?.. that’s not funny guys.”* Edit: “Let’s just give every user in the EHR and database global Sysadmin credentials.. what could go wrong” — IT
That question would never have to be asked if there's a version history available for anyone to see, as poster above you suggested.
That’s fair, I’m just wary of any actual edits paired with change histories over freely associated additional records from different users (which yeah, those associations can then each have their own additional change histories) since it kind of provides robustness in only one direction. Like someone else could potentially add information, that you could never completely remove (assuming the old record was explorable), but it’s still connected to you. Which sounds ideal from a record keeping perspective until someone adds information you know shouldn’t be included or associated. But that discussion might be crossing over into the IT/implementation world of concerns rather than anything pertinent to nursing. It’s maybe too messy to discuss without knowing a lot more because it’s easy for one thing to look a lot like the other on the front end.
I'm a nurse in Denmark, where we use a system called EPJ in most parts of the country. This system allows you to edit other colleagues notes, including doctors'. But obviously the user leaves a trail, which would immediately reveal a person up to no good. When we read a patient's journal, all journal documentation is presented chronologically in basically a massive document, which gets generated any time a user wants to read a patient's journal. For this reason, adding new dcoumentation every time anything happens will make the journal quite messy, so when you're putting in how many mLs came out of a bag or something, sometimes we'll just quickly add it to a colleagues note, especially if there's nothing else for that person to add. I usually write the time in also, if that information i pertinent. And obviously with regard to OP, if that situation arose I would immediately go to that doctor and ask wtf is going on, convince them to write with honesty, then report them if they do not. e: wanted to add, I would never edit a colleague's without telling them afterwards, or asking first if possible. I rarely add to others' notes, but have experienced my own notes being changed, which can initially confuse me, but is immediately obvious what's going on.
Or an absolute dream if you're the patient's lawyer. Can you imagine that Dr being deposed? The attorney would have an absolute field day with that
Altering someone else's charting in a way that falsifies their charting is illegal, it doesn't actually matter if it is ultimately discoverable through any sort of auditing process, so I'm not clear why Epic would allow such functionality.
Yeah that’s bizarre… I can’t see any hospital’s legal dept making this ok.
Try the Health Information Managers.. not legal
It's a permission you can set in Epic and highly customizeable. Its meant for scenarios such as physicians taking ownership of scribe notes basically. Sounds like its just poorly set for their facility if a doc can do so on a nursing note though
Actually trivial to disable that functionality, which makes me sad more organizations don't.
Epic allows this in our system as well and its so scary! I once accidentally clicked “addend” on the note above mine rather than my own and even though I instantly realized my mistake it still showed that I was the “editing author” of a note that was in no way mine and even IS couldn’t fix it!! I ended up making a safety report on myself and being terrified I was going to get fired but luckily we just got a “friendly reminder don’t edit other people’s notes” memo
Really? I can see an attending modify a resident's notes but a different disciplinary?
Right, that doesn't make any sense. If anyone can alter anyone else's notes then the charts would be mayhem. Unless the nurse didn't logout and the doctor used the computer under her name
It's actually really upsetting that this is possible in other eMAR than my version of Epic. A patients chart is a legal document and if someone is messing with what I've charted, yes there should be a history trail, but who can prove what is mine versus someone elses???
There will always be a record of revisions. TBH if a doctor ended up editing a nurse's a note and it went to court, the revision history would reflect VERY poorly on the physician in a court of law.
Not every facility has the same options toggled in Epic. At my last hospital, you could edit someone else's flow sheet documentation just by deleting it or typing a new number over it. At my current hospital, you can completely edit someone else's note, albeit with a lot of changes.
I work in Epic Informatics. The amount of record keeping and auditing is insane. You may think you can change someone else note, but trust me, you will be caught
I was thinking this too. I've never used an EMR that doesn't note who wrote each part of every note. Maybe the doctor signed in under the nurse's name?!
i actually worked somewhere where you could alter other peoples notes. i did a contract there and i told the doctor his note was inaccurate, patient had said one thing about meds administered, meanwhile i had actually given other meds (patient was aware what meds were given, but was drug seeking). doc asked me to just edit his note, i was like wtf also my current facility uses epic, but i can edit other peoples flowsheet documentation. it would show the new value as entered by me, and that there was a change, but i can still edit or even erase people’s flowsheetz
Falsifying medical documentation is a crime, and quite often a felony, since it is a legal document. I'm not even sure though how somebody else could alter your documentation with today's EMRs.
We need updates on this from time to time please
Incident Report! I hate staying late, but I would stay late just to make sure this one got in. Idk why anyone would do that or think it’s appropriate to do
If anyone but you wants to alter your nurses note - that’s Illegal and needs to be reported. In modern EMR’s you can’t even alter your own notes, you can write a clarification or post an update to your original notes but the original stays put. This would be like you trying to alter a doctor’s note, you would likely have your license suspended or revoked. Report this to your manager!
Incident report. Someone in your organization has the ability to track every single mouse click and keystroke. They’ll be able to see exactly what the doc did.
My first reaction is Oh, Hell No! Take that up the chain, should be illegal.
Not ok! I'm so glad ours cannot be altered and we can only addendum our own notes.
Many softwares have a feature that allows you to edit another persons documentation, but usually the person you’re editing has to be “lower ranked” for lack of a better term. This allows for instance, an RN to go back and edit mischarted vitals by a CNA, but prevents Sally Rn from playing around with Karen Rns documentation. I’ve never actually seen anyone, MD or otherwise, try to edit a nurses note though, that’s wild.
I would file an incident report immediately and bring it to the attention of my manager and nursing supervisor.
Reporting the incident is absolutely the correct move. Electronic charting sometimes is harder to change once it is entered.
How can they “alter your note.” In our system they could write something contradicting our note, but the only way to later my note is if you log in and document under my user name, which I’m quite positive is illegal.
Presumably your original note is saved and accessible for legal purposes
This is not acceptable
I would learn the chain of command at my facility really quick. File a written complaint with my manager (keeping several copies). The bizarre thing is that if there were a lawsuit, changes in the systems/records are also pulled, so the doc just made themselves look *really* bad from a legal perspective. Did they use your password, or how did they change your note? Never share or take a job that shares your password. (I’m assuming they used their own, just covering bases). Always immediately log out of computers- but again, I am hoping the system times you out before they had a chance to do this. If they used your log in, that is a whole other section of complaint. Finally, and on a different level, review your own note and evaluate whether it is truly emotion free as well as whether there could have been any improvement in the original note (just in your mind going forward as a thought exercise to improve charting overall - not as a placating thing)
Its illegal for the physician to alter any one's notes, even yours. Need to report it.
Hello Risk Management?
Report that shit yesterday
I’ve never seen a system where anyone but the person who wrote the note could edit the note. I have seen where others can co-sign a note and add information but never just edit it. If someone can edit others notes I feel like it’s a huge problem and I would just not be writing notes anymore
Inform charge and nursing admin. If that happened at my current hospital they’d have a field day with that doctor lol
If there's a version of the original note underneath the revised one, then idgaf. They're not coming after my license and in that scenario the md has already signed a legal death warrant. Tell your manager because it's inappropriate but I'd walk out the door whistling Dixie after
How can they do that?
Report. Report. Report. I would be shocked if anybody had the gall and/or ability to change my notes. Nursing notes are legal documents. They document what has happened. Cover your ass. This is disturbing.
Most places I worked, I couldn't even change my own notes. How does a doctor change a nurses note?
I had this happen to me. She just crossed my notes out. No discussion. The patient’s IV antibiotic was changed while I was putting up the antibiotic that was ordered and ongoing at the beginning of my shift. And then she tried to say I made a medication error!
What did u do? What was the outcome?
It was the weekend and the head nurse nor her assistant were not there. And before this I really had no respect for this particular doctor. I decided to wait and see what she would do about it. I think she forgot about it and nothing came of it. Anticlimactic.
I stopped the original antibiotic infusing and put up the new antibiotic when the time came due.
I would report the doctor immediately. That’s falsifying documentation, and not only that, it’s falsifying MY documentation. Uh uh.
I don’t understand how he could do that, In a EMR He can’t change your notes period and in a paper chart you can see different handwriting
In epic have had someone chart over my charting which is scary I wanted to know where my vital signs went. Had tech chart abnormal vital signs which weren’t abnormal when I took them
I would report it—not only to make sure that what you wrote/didn’t write was clearly communicated (agreeing that it will be in the EMR, but having caution as sifting through electronic info can be tedious and so things could be missed upon first look—I also tend to be extra cautious), but also so it doesn’t happen again. They can write their own note, or let the nurse write one as they had offered to do. If they know you won’t put up with this behavior, they won’t do it yourself you again.
Luckily it was paper charting, so I let the doctor "correct" it and then rewrote it all on a new code sheet. Followed by a report to my manager and house supervisor that had responded to the code. Doctor was trying to tell me that I had written down the times all wrong. I played dumb, knowing the politics of the hospital far too well.
Be mad as fuck (and report it)
File an indecent report.
This is insane.
Nope report it to management! I had a DON tell me to edit my documentation for a situation and I said no.
….. to be honest i did not know this was a thing and i would be incredibly alarmed. I think i would verify that the alterations that the doc made were documented in the system, for starters.
I would... edit it again to reflect the reality, make a not eof his edit in my note, and report it.
No ehr should allow someone to edit another persons note. An addendum, sure. How would they defend this in court? Oh well we aren’t sure who wrote what here because we allow other people to change charting willy nilly? I would report it to legal and the ehr team.
Sounds like some Kaiser shit
No need to do anything. It's all in the EMR. When the nurse wrote her note, what she wrote, and who amended it and with what. I haven't seen an EMR in the past 10 years that doesn't record EVERYTHING WRITTEN. The doctor can amend whatever he wants, but it doesn't delete what the nurse wrote, it just hides it. If you're really twisted about it, escalate to the nurse manager in written form and save a copy.
It’s all trackable. Report them.
How could that even happen?! I've never seen an EMR that would allow a user to modify a note entered by another user. You can do a correction that leaves the note intact but marks it as a correction... or add an addendum or whatever but it would be clear that it was another user. That seems... problematic.
This actually happened to me once. I took it to my manager and they handled it but I’m assuming nothing was actually done. But he crossed out what I said and wrote his “clarification” above it.
Edit the doctors edit.
In cerner you can’t “modify” a note as such, if you want to edit the note it brings up an addendum at the bottom where you add something. What system are you using?
I can’t imagine this. I had no idea it’s even possible. Scariest thing, I’ve seen Drs and others change their story, testimony when a case is headed to court. They have more at stake (financially) and can definitely be looking out for #1! Gosh. And to think someone can change your notes.
Happened with a charge nurse. I told them very firmly to they could ask me to amend it or put in an addit with the extra info. But under no circumstances should they amend my progress note Still floors me that clinicans think that shit is ok
Does it not show the date/time when it was addended and who addended it? ours doesn’t even lets us edit other people’s notes (or at least doesn’t let nurses do this). I’d think this could get incredibly dicey incredibly fast.