Is it legal for one nurse to alteranother nurse’scharting?

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Is it legal for one nurse to alteranother nurse’scharting?

I am an RN. I discovered that a co-worker RN altered my charting because she disagreed with my assessment of a patient, though she’d never seen the patient. She signed the changes with her initials. Of course, I’m outraged, and have notified our nurse manager, but is it legal for one nurse to change the charting of another?

Asked on September 5, 2010 under Malpractice Law, Tennessee

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 11 years ago | Contributor

There is no law specifically on the subject. The issue is whether or not malpractice was committed, in terms of whether they may be any liability on any impact on a license. There's also the issue of whether dong this violated any internal hospital (or clinic or practice) rules. What she did could create liability, if a patient suffered any harm do it, and again, could represent a violation of workplace rules, affect any medical/nursing licenses, etc. if it was improper to do this, but there's no specific law stating that one nurse cannot change the chart of another. It is a matter that you can and should discuss with the nurse manager, to find out what your institution's policy is and resolve the situation.


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