Altering documentation: the importance of documentation cannot be overstated. Any attempt to alter it retrospectively, especially when a nurse's practice may be under scrutiny, is bound to be censured.
The issue of nurses altering documentation when faced with an investigation by the Health and Disability Commissioner (HDC) has recently come under the spotlight. Two registered nurses (RNs) in Health Practitioners' Disciplinary Tribunal (HPDT) decisions last year (242/Nur09/122D and 269/Nur09/123D) were found guilty of professional misconduct because they altered patient records, created new patient records and failed to document care. (1,2)
The referral to the HPDT arose from an investigation by the HDC office into the care provided to resident Mrs A at Birkenhead Lodge Retirement Home in 2008. (3) The provider was named, as is now the custom of the HDC office. This followed complaints from Mrs A's family after Mrs A was admitted to hospital for the treatment of pressure sores, having lived at the home for two years. During the investigation, the documentation of care provided Mrs A was questioned. The Commissioner's office revealed that some records were created to fill gaps. Examples included creating entries in the wound chart, creating an annual residents' health care review, creating an observation chart based on records in the progress notes, rewriting an activities plan, adding entries to the nursing care plan and additional information to progress notes.
Professional misconduct is defined in section 100 of the Health Practitioners' Competence Assurance Act 2003 (HPCA Act). (4) In this instance, both RNs' actions amounted to professional mis conduct by their acts and omissions in practice. They were judged to have brought discredit on the nursing profession.
How common is it in nursing to create false documents? American nursing ethicists Marcia DeWolf Bosek and Marcia Ring have explored the ethical underpinnings of documentation in health care settings. (5) Interestingly, they describe a situation where a charge nurse instructs another employee to fill in the gaps in the client's progress notes. The facility had been previously audited and was cited for insufficient documentation. This, too, was the finding of the H&DC investigation in the case of Mrs A. (3)
The rest-home manager (who was one of the owners and an RN) asked a second RN to assist in making the documentation tidier and more thorough. She also asked a caregiver to complete a document. Until then, the second RN was not part of the investigation. Her actions in creating and rewriting documents found her in breach of the HDC code of consumers' right 4.2, as she did not adequately document the care she provided. (6) The rest-home manager was found in breach of rights 4.1 and 4.2, including a breach by the rest-home of right 2 of excessively charging for services that were not provided (eg podiatry services and a doctor's visits). An investigation by the district health board occurred. The HDC office had evidence the documentation was misleading, implying the entries were contemporaneous when they were not. Electronic footer dates on forms were different to the dates written, proving to the HDC office the documents had been falsified.
Both RNs were referred to the HPDT by the Director of Proceedings whose functions include reviewing cases referred by the HDC and making an independent decision on whether or not to take any further action. (7) Both RNs were fined significantly, censured, had to pay costs to the HPDT and referred to Nursing Council for competence reviews. The HPDT was very clear in its disapproval of health practitioners attempting to mislead the HDC or others when complaints are being investigated. (2)
Documentation in health care serves many purposes. Ultimately it is an account of the care provided in our health and disability system; it allows for other practitioners to understand the care given, plus it provides advice on care options or sets a pathway of care. Accurate documentation is an essential part of a health professional's work and is integral to meeting Nursing Council competencies for RNs, enrolled nurses and nurse practitioners. (8,9,10) The same applies to the Midwifery Council's competencies for midwives. (11) NZNO's updated publication on documentation offers a list of "dos" and "don'ts", and includes a warning that any information added retrospectively must be dated and re-signed, with the date any addition is made.
The Health and Disability Service Standards 2.9 (pp20-21) states consumer information should be accurately recorded, current, confidential and accessible when required. Health information should be written dearly, objective, factual and signed, with the time and date recorded by the health practitioner making the entry. (12)
The nursing profession needs to scrutinise the decision-making and conduct of RNs who alter documentation or misled public advocates like the HDC. The issue also warrants closer inspection of New Zealand's health and disability providers and the audit principles used by the Ministry of Health.
(1) Health Practitioners Disciplinary Tribunal (2009) 242/Nur09/122D. www.hpdt.org.nz. Retrieved 10/09/10.
(2) Health Practitioners Disciplinary Tribunal (2009) 269/Nur09/123D. www.hpdt.org.nz. Retrieved 10/09/10.
(3) Health and Disability Commissioner. (2008) Case 08HDC08672. www.hdc.org.nz. Retrieved 10/09/10.
(4) Health Practitioners Competence Assurance Act (2003) www.legislation.govt.nz. Retrieved 10/09/10.
(5) DeWolf Bosek, M.S. & Ring, M.E. (2010) Does good documentation equate to good nursing care? JONA's Healthcare law, Ethics and Regulation; 12: 2.
(6) Health and Disability Commissioner. (1996) Schedule Code of Health and Disability Services Consumers' Rights. http://www.legislation.govt.nz/browse_vw.asp?content- set=pal_regs&clientid=220696&viewtype =contents Retrieved 19/02/09.
(7) Keenan, R. (2010) Health Care and the Law. 4th Ed. Wellington: Brookers Ltd.
(8) Nursing Council of New Zealand. (2009) Competencies for Registered Nurses. Wellington: Nursing Council of New Zealand.
(9) Nursing Council of New Zealand. (2010) Competencies for the Enrolled Nurse scope o-f practice. Wellington: Nursing Council of New Zealand.
(10) Nursing Council of New Zealand. (2009) Competencies for the Nurse Practitioner scope of practice. Wellington: Nursing Council of New Zealand.
(11) Midwifery Council of New Zealand. (2007) Competencies for entry to the register of midwives. Wellington: Midwifery Council of New Zealand.
(12) Ministry of Health and Standards New Zealand. (2008) The Health and Disability Service Standards. (NZS8134: 2008) Wellington: author,
By professional nursing adviser Suzanne Rolls