Nurses and other healthcare professionals are forewarned that in recent years, patients have become more perceptive in regards to overseeing their health care. Patients are taking a more active role in their care and the care of their loved ones.
Many patients require clarification of their health situation and treatments; therefore, they use computers, which disseminate a vast amount of medical information at their educational level. This produces a more knowledgeable patient.
Patients are more aware of their rights to a copy of their medical records, which they can scrutinize for any errors. Many malpractice attorneys are advertising on the internet and disclosing the elements of an eligible claim, even offering free case reviews.
This has increased the likelihood of a malpractice lawsuit. The media publicize debates doctors have with the increasing cost of malpractice insurance and limits of malpractice lawsuits so patients are aware of these issues.
I have a copy of my husband and my hospital records and noted false documentation throughout by the nurses and physicians. While my husband was hospitalized for colon cancer and a resection, I was at his bedside.
I noted how nurses documented a complete initial assessment in his records without touching him.
If his assessments were done as documented, he would not have had to wait 7 days and almost die before receiving emergency surgery for a strangulated herniation.
When I reported the hospital and staff to the Joint Commission, I asked that they pay close attention to the false documentation of care he did not receive.
I remember in nursing school we learned that if it is not documented, it was not done. What if it is documented but not done? That is the definition of false documentation.
In my medical records, false documentation was discovered throughout my emergency room notes. The nurses in triage perform vital signs and send patients back to the waiting room within 10 minutes.
In my records, the triage nurse documented a total assessment including checking my peripheral pulses and pupils. In the documentation, the nurse noted that my back was nontender with full range of motion but I was there for back injury pain due to a herniated disc.
The nurse practitioner also documented a full assessment, she briefly listened to my lungs otherwise she just documented the history of my complaint for the physician.
I have been disabled due a back injury related to a car accident in 2006. I have to inform the disability retirement office that the false assessment and documentation does not reflect my complaint or problem.
When reviewing my records, it appeared as if I was seen in the emergency room requesting analgesics without presenting any physical signs and symptoms. It appeared as if they were dispensing medication without a cause, especially since the medication was a narcotic.
I am in a pain management program but missed my appointment (the nurse practitioner documented that my doctor was on vacation) so I just needed pain medication for 4 days, the next appointment.
I have seen nurses falsely document bowel movements, which the patient has not had for 3-4 days. The patient needlessly suffered nausea, vomiting and poor appetite when it could have been avoided by treating for constipation.
I have taken care of a patient assessed by previous shift nurses who documented pedal pulses were present. The pulses were not only absent but also the foot was blue and cold. Some nurses tend to be too busy to pull the blankets completely off and do a real assessment.
In 1994, I admitted a patient with AIDS and Kaposi’s sarcoma (large purple blister-like lesions rarely seen these days). The next shift nurse was afraid of AIDS patients so she never went near the bed but she documented an assessment. The patient died before morning but she was unaware.
The doctor questioned her regarding his care; she stated he appeared to be breathing when viewed from the doorway on rounds. Apparently, he died 2 hours before the doctor made rounds.
The nurse was removed from patient care and confidential legal action was taken. I gave a deposition of his condition when I signed off but I do not know what else was done. She was placed in the mailroom during investigation and prior to termination.
All healthcare personnel must understand that these legal records are a means for communication between caregivers, therefore if any records are false, negative findings may be omitted causing great harm and even death to the patient. In addition, it can become a legal issue and grounds for malpractice.