need help ASAP

Question

 A patient's chart has been subpoenaed for pending malpractice litigation. In preparing the chart, you discover an error that was made when the results of the laboratory report were incorrectly documented in the chart. You have the original laboratory report. What should you do? Explain your reasoning

Answer 1

It depends who "you" are, and where the laboratory report was documented in the chart. If it was part of the nurse's or doctor's documentation, what I would recommend is bringing it to the attention of the legal department since the chart has been subpoenaed for malpractice litigation.

 

You cannot change anything that has been documented as this is part of the legal record, right or wrong. It also depends on what is wrong with the documentation. If the wrong patient's report was filed in the chart, then it needs to be filed in the correct chart. If the laboratory results were recorded incorrectly on a flowsheet, then it may be too late to make an error notation on that documentation by drawing a single line through the error, dating it, writing the correct information and initialing your entry.

 

If medical or nursing decisions have already been made on this report, and the report belongs to another patient, there should be an incident report filed and turned in to the quality department. The report should not be filed in the patient's chart, but a notation may need to be made in the chart, depending on what was incorrectly documented, along with the date of discovery.

 

So, the answer is somewhat complex, the only certain thing being that you cannot alter or remove the original documentation. You may add documentation, depending on what has happened, dated as a late entry, and you may need to fill out an incident report to file with the quality department. The very first thing you should do is report your findings to your supervisor, unless you are the supervisor. Then report it to the legal/risk management and quality departments.