12/14/2021
Are your client’s medical records tampered with? 😱
Nurses see medical records and charting every day we work. We are able to catch on to documentation that doesn’t sound right or is tampered with. When this happens we request an audit trail to be done and receive the metadata to compare to the records that were given to us.
There is an abundance of information that can be revealed in the metadata.
My fellow nurses please be careful with what you are charting and where you document because everything is being watched. Everything can be questioned.
Don’t open someone’s chart if you are not caring for them 😥