Back again with documentation questions.

I've always been told to chart what patients say and if I'm asking a question I have to chart the response.

Today I was asked to alter the charting as the patient complained about the experience he had previously at the facility when I asked him a related question. I was asked to summarize instead as "patient voiced complaints".

Thoughts?

Also, aren't altered notes discoverable? So what would be the point in editing charting?

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Seems unethical but moving forward maybe modify the way you chart

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In my position we work from home but speak to patients and when there are complaints such as a bad previous experience, we can put in that kind of "summarized" note like "voiced complaints" but we're asked to send an email to management with the details so the practice manager or somebody can follow up with the patient according to the situation.

And yes. Patients can see those notes unless it's blocked. I think the setting in epic says "blocked for patient safety" or something like that.

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So instead of listing the specific things (complaints) they had, you are being asked to just summarize instead? My thoughts are that this is something waiting to blow up on somebody's end, but I’m not really sure if it is more common in some places or what.

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Nope I would write it like it supposed to be done if you get in trouble get the state involved

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Sounds shady. I remember a RN getting fired ‘for’ editing her charting - weird.

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