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

July 2004 
Volume 34  Number 7
Pages 14 - 14
  PDF Version Available!


  • 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 ...

Purchase Now !

To purchase this item, follow the instructions below. If you’re not already logged in, be sure to enter your login information below to ensure that your item is saved to your File Drawer after you purchase it.

Not a member? Join now for Free!

1) If you're not already logged in, enter your information below to save this item in your File Drawer for future viewing.

User name:


Forgot your user name or password?
2)  If you have a coupon or promotional code, enter it
here.(If not, just click Continue.

Digital Coupon: (optional)

3)  Click Continue to go to the next screen, where
you'll enter your payment details.

Featured Jobs

Benefits of Membership

FREE E-Newsletters
Sign up for our free enewsletters to stay up-to-date in your area of practice - or take a look at an archive of prior issues

Join our CESaver program to earn up to 100 contact hours for only $34.95
Register Now

Explore a world of online resources

Become a Member