ADVICE, P.R.N.: A blot on the record

July 2004 
Volume 34  Number 7
Pages 14 - 14
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  • Figure. No caption a...

    Last week my pen leaked ink all over one section of a patient's medical record, obliterating what I'd just written. Because I'd just finished charting, I quickly reconstructed my notes on a new page and threw away the original. Of course I attached a signed and dated note explaining why I'd rewritten the page. Now I'm wondering if I should have kept the original. Am I in trouble? —H.W., MINN.

    Figure. No caption available. Maybe. If the page were to become evidence in a court case, a jury could draw an unflattering inference from the fact that you threw away the original. For example, they might conclude that you were covering up some incriminating evidence. Remember, original medical records, however messy, are legal documents and shouldn't be destroyed.

    Tell your nurse-manager what happened and file an incident report. In the future, rewrite your documentation only when the original ...

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