General Discussion
Related: Editorials & Other Articles, Issue Forums, Alliance Forums, Region ForumsMedico-legal question - honesty in records.
Last year, my employers at the pediatric office started something that bothers the hell out of me. If a child gets a flu shot somewhere other than our office, it doesnt show up in the immunization report section of our EMR (electronic medical record). We have been instructed to enter a random date in the immunization record, showing that the child had the flu immunization.
There is a huge Big Brother thing going on in medical documentation now, and everybody is doing a lot of CYA. The implication seems to be that if there is not a specific date in shot record, it indicates that we did not care enough to make sure the kid got the vaccine so we are being negligent.
Just yesterday, I heard my boss call to one of the staff nurses, Mary, make up a date for the flu shot - October 15th.
I find this horrifying. It is lying in a medical record. We dont just make up dates for the immunizations required for attending public school.
I wont do it. I may get my ass in a sling with my boss, but I wont do this. Ill state in my narrative that, Parent says Susie got the flu shot at Walgreens last month, or whatever, but I wont make something up.
Response to 3catwoman3 (Original post)
Name removed Message auto-removed
3catwoman3
(24,023 posts)...to call whatever facility administered the shot, right during the visit, and Im fine with verbal confirmation.
Ive never had a record called in to court, and i hope to keep it that way until my anticipated retirement in 2021 (by then, I will have been a pediatric nurse practitioner for 45 years - time to hang it up).
I know that when a record is part of a law suit, the plaintiffs attorneys go over every letter of the chart with the proverbial fine-tooth comb. It wouldnt surprise me if that were to include verifying immunization dates, and if one were to be found, arent we setting ourselves up for increased suspicion that other entries in the chart are untruthful?
Phoenix61
(17,009 posts)Document everything accurately. "Parent reports little Sally got her flu shot last month" seems like a great way to go.
boston bean
(36,223 posts)Went for annual physical and the pharmacy sent the record to my doctor. Doc said great, I see you got your flu shot at the pharmacy.
Hoyt
(54,770 posts)If someone tells the office that they got a flu shot elsewhere, I'm sure the doc or staff asked when. My new doc asked the samem for colonoscopy and some other stuff. If the patient doesn't know the exact date, what is the alternative? I guess one could say "apparently some time in October 2018." But the EMR might actually require a date.
I think the doc likely knows what they are doing, and whether it's October 3, October 15, or whenever they got it, doesn't make a lot of difference unless there is a recall or something. Point is, I don't really think you are making something up that will affect patient care if the parent can be trusted. Now, if the doc tells you to make up a date for a Pneumococcal vaccine (that was not administered) and bill it to insurance as if your employer administered the vaccine, that's an issue.