Patient Document Tampering: Critical Issues, Recommendations, And Implications

Main Issues that Emerge in the Case Scenario

Discuss about the Patient Document Tampering.

In the nursing practice, documentation is crucial as per The Australian Registered Nurse Standards for Practice. Documentation refers to the written or the electronic health records which provide the patient’s information. The Australian Registered Nurse Standards of Practice requires that the nurse on duty should record the patient’s details accurately, update the patient’s file in time, keep it under safe custody and maintain the confidentiality of the information recorded (Kerr, Lu, & McKinlay, 2013). The safe maintenance of health records of a patient facilitates effective communication between the nurse on duty and the other nurses and care providers about the status of the patient, nursing interventions carried out and the outcomes. Also, documentation promotes proper and efficient nursing care. In the case scenario, personally, as a nurse, I would examine myself for the cause of the discrepancy, inform my supervisor about the issue and other relevant top personnel to launch investigations (Johnson, et al., 2014). Furthermore, I would come up with an incident report. In the essay, I shall identify critical issues and recommend appropriately, discuss the actions to be taken, outline the relevant parts of the Australian Registered Nurse Standards of Practice which applies to the case scenario and, discuss the potential legal and ethical implications.

In the case scenario, the nurse on duty fails to keep the patient’s records safely, and as a result, somebody accessed them and tampered with the original records. The tampering with nurse’s original notes is quite detrimental in the nursing care because it would lead to either the falsification of the client’s information or provision of erroneous information. By doing so, it shall conflict the key role of documentation as outlined in the Code of Professional Conduct for Nurses which requires them to provide impartial, honest and more accurate information regarding the nursing care and the patient receiving the care (Kleinpell, et al., 2014). Also, through the provision of accurate and authentic information regarding the client helps to build and maintain the community’s trust and a high level of confidence in the services provided by the nurses. But, on the contrary, the nurse on duty practices against this code of professional conduct.  Furthermore, the Code of Professional Conduct for Nurses in Australia requires the nurses to treat the personal information acquired from the patient in a professional way and capacity in ensuring that it is kept private and confidential. Though, in the case scenario, it is evident that the nurse on duty did not observe this professional guideline which requires her/him to keep the information privately and confidentially and instead left it carelessly and openly (O’connell, Gardner, & Coyer, 2014). The act of the nurse on duty to leave patient’s information in the unsecured area resulted in its easy access by intruders who might have tampered with it.

Immediate and Subsequent Actions

Similarly, the tampering of the nurse’s original notes would lead to the strained and poor therapeutic relations between the fellow colleagues, client and her/him. Strained and poor relations arises as a result of mistrust and inner feeling that either the colleagues developed jealousy on how she/he offers her nursing care services to the client and are getting unwise mechanisms to land the nurse into problems (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). The aim of fellow nurses is to see the nurse in problems with the unit supervisor or management, and if possible, the nurse gets deregistered or suspended. Besides, the patient might develop mistrust with the nurse on duty, and think that the nurse attentionally tampered with the notes. The patient will reason so that during handover, the incoming nurse should not get the right information about the care required and end up offering or prescribing different drugs which would result in dire consequences for the patient’s health (Johnstone, 2015). Such actions are against the Code of Professional Conduct for Nurses in Australia which requires the nurses to promote and maintain the trust and the privilege inherent in the existing relationship between the nurses and the patient receiving the nursing care.

In the Australian Registered Nurse Standards of Practice, Standard 1 states that a nurse should think critically and undertake thorough analysis in the nursing practice to make informed decisions. In the case scenario, there are quite a number of protocols to be observed under Standard 1 in the efficient handling of the case. To start with, procedure 1.4 of the standard 1 practice require nurses to comply with the legislation, regulations, the policies and the guidelines while on duty (Bernoth, Dietsch, Burmeister, & Schwartz, 2014). For instance, different health care organizations do have specific policies and their guidelines regarding the launch of complaints and investigations. Therefore, as a nurse, she/he should make a step of informing the relevant investigation bodies to examine and investigate on the tampering of the original notes.

Additionally, the issue of lack of critical thinking and analytical skills emerged. In the case scenario, the nurse failed to think critically in various contexts. Firstly, the nurse would have thought to be unwise leaving the patient’s records carelessly and unsecured. She/he would have taken a depth reasoning and make a ruling that either some patients or other nurses may come across the health record diary or book and interfere with the information intentionally or accidentally (Kangasniemi, Pakkasen, & Korhonen, 2015). The nurse would have taken into close consideration that leaving the record openly some mentally challenged patients may get it and pluck some papers containing vital patient information. The failure of the nurse to think critically and analyze the situation is contrary the with the Australian Registered Nurse Standards of Practice which requires the nurse to think critically and making thorough analysis in nursing practice. As per the standard 1, a registered nurse should use a variety of strategies to think and make an informed decision based on the available evidence in the provision of safe and quality nursing care within the patient-centred and available evidence at the line of work (Ralph, Birks, & Chapman, 2015). Furthermore, the standard 1 requires the nurse on duty to maintain a more accurate, comprehensive and in time documentation of the assessments, care plan, and client evaluation.

In addition, the issue of accountability and responsibility emerges. In the case scenario, the nurse on duty was to be held account and responsible for the destruction of the health records of the patients. He/s he should come out and explain to the investigating bodies of what happened and how it happened. The nurse should act under the Australian Registered Nurses Standards for Practice, Standard 3, which shall require her/him to prove her/his capability and capacity in the nursing care practice (Birks, Davis, Smithson, & Cant, 2016). The registered nurse shall be expected to accept and take accountability for the incapacity to make informed decisions and take appropriate actions in ensuring that the client’s health records are safe and updated for a better heat outcome. The nurse should be held accountable to clarify briefly on where he/she was while the destruction was taking place or where she left the document. She/he should answer interrogative questions seeking to know whether handing over happened or not, or the tampering of the records occurred while she was still on duty.

As a witnessing nurse, I would immediately report the matter to the unit supervisor in service. As a nurse, I would consider this as my first step in observation to the Code of Ethics for Nurses in Australia. The Code of Ethics for Nurses outlines all nurses should seek to make informed decisions. With that regard, as a nurse, I would inform the supervisor on duty so that we can discuss on the way forward and we should handle the matter at stake to ensure that the patient gets access to quality care (Cusack, 2015). We could be forced to start new recording of the patient’s information since we would not risk using the tampered document. Having the original notes plucked or deleted is quite disastrous as it may lead to using false information regarding the patient and the care required. Furthermore, relying on such altered information would result in health consequences on the side of the client, in case, nursing care relies on it. Shall report in order to uphold the Australian Code of Ethics for Nurses which directs that the nurses should value the ethical management of the patient’s information (Hunt, et al., 2015). Besides, as a witnessing nurse, I shall follow the appropriate channels as per the organization on the policies and the procedures for the safety reporting. I would draft an incident report regarding the case scenario. 

Standard 1, which states that the nurses should think critically and make analyses to make informed decisions in nursing practice. Through critical thinking, decisions shall be reached based on the available evidence. The critical thinking results in the provision of safe and quality nursing care services within the patient-centred and the evidence-based frameworks. In the subsection 1.6 of the Standard 1, it applies to this case scenario (Westbrook, et al., 2015). The subsection requires the nurse on duty to maintain an accurate, comprehensive and up to time updated documents for her/his assessments, care plan, basis of decision making, treatment actions and the evaluations made. Finally, the standard of practice applies to the handling of the case scenario. The witnessing nurse, supervisor and the investigation personnel should critically and creatively think about how to handle and arrive at a reasonable solution to the problem.

Standard 3, the nurse should maintain the capability and capacity for practice. In the case scenario, the nurse on duty should be liable and be ready to be held responsible and accountable for not ensuring the safety of the patient’s records as per the requirement of the Standard of Practice (Harrison, et al., 2014). The subsection 3.4 of the Standard states that, the nurse should accept and be accountable for the decisions, her/his actions, and behaviours, and the responsibilities bestowed on him/her. It is true that the nurse on duty had the powers to ensure that the patient’s records are kept in a safe custody and should take all responsibilities in case the patient’s file gets destroyed.

There would be a possibility for the nurse to be fired/suspended or deregistered if the investigation body finds enough evidence that the nurse was incompetent, careless and irresponsible capability in practice. Furthermore, if there is adequate evidence which can justify that the nurse on duty internationally plucked the original notes with an aim to hinder either the handover process or other reasons, she would be fired and deregistered (Haw, Stubbs, & Dickens, 2014). Other possible legal implication would be the family members of the patient heading to court to file on denied quality nursing care and disclosing of their patient’s private information. Finally, the unethical practice may emerge in which the nurse who is being held accountable, may choose to come with a falsified information in order to try to convince the supervisor and the investigation team that is the original documentation only that he confused. Lastly, the ethical implication would arise where the nurse develops mistrust with her fellow nurses by thinking that one of them tampered with the original notes to land her on problems. Also, there would be mistrust between the patient and the nursing fraternity.

Conclusion

It is evident that nurses on duty should practice their nursing care adhering to the Code of Professional Nurses Conduct and the Australian Registered Nurse Standards for Practice. The practice as per the Nurses’ codes of professionalism aims at the building the community’s trust on their services and ensuring that safe and quality nursing care services offered. Furthermore, proper and accurate documentation of the patient’s information concerning his/her treatment status and the care delivered is crucial. Keeping written and electronic health records of patients facilitate effective communication between nurses and enhance comfortable handing over during nurses shifting. It is also important to maintain the documents in safe custody and is accessible by only authorized personnel such that if there is tampering of the document, there would be easy tracking. Finally, the patient’s information should be kept private and confidential. Through ensuring that the client’s health information is kept private to other people who are not responsible for his/her care, helps to build the client’s trust on the care services provided by the nurse on duty.

References

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