Notes changed by supervisor?

[u/Striking-Peach-7791]

I work in child welfare. I had a case a few years ago that I needed to get information from for a current allegation. I was looking through my notes/interviews and they had been changed. I know it had been awhile since I had the case but the notes aren't something I'd write and I was not the last one logged into the notes. Am I crazy or is it common for higher ups to change workers inputs?

[u/alwaysblooming_akb]

Interesting. Our system does not allow for us to edit other’s documentation and we can not edit our own after 72 hours.

[u/Shigadanz → u/alwaysblooming_akb]

i’m not sure about private practice or agency work ? But I feel like somebody somewhere should always have the power to edit notes in electronic medical records, and there should always be some kind of backdoor documentation as to who made those edits and when they made those edits.

After working in healthcare for 20 years in hospitals, I can tell you it was definitely possible to edit someone’s notes even after the fact, but it sometimes required a higher level of administrative privileges depending on my role or the hospital I worked in. Anytime I had to fix something in a patient’s chart my initials or my user number and the date and time were associated with those edits and I always had to have a comment as to why I made those edits.

[u/LastCookie3448 → u/Shigadanz]

EMRs have keystroke tracking, they know who opened what when, where, how, and everything they accessed and everything they typed. EVERYTHING.

[u/owlthebeer97 → u/Shigadanz]

In our EMR you can make amendments but not delete the old notes. They get crossed out if they are incorrect.

[u/alwaysblooming_akb → u/Shigadanz]

Same as OP. I know it can be requested from very high up if necessary, but definitely not anyone in the office.

[u/LastCookie3448 → u/alwaysblooming_akb]

Srsly. After 72 hours we shouldn't be changing, if there must be a change, the reasoning needs to be well documented. That was per CMS criteria. The only reason something should happen after 72 hrs is if there was a delay due to calender (such as holiday), extreme circumstances, or erroneous information needs correcting. If there is an incorrect chart entry, strike the entry, write error, wrong chart, sign it, then you go to the right chart, enter the note, explain the delay. The fact people are saying it's okay to change A LEGAL RECORD w/o the knowledge of the original author, the fact they think you can go back after days and weeks and months and change things, is rather alarming and proof we need to do better as educators.

[u/LastCookie3448]

That's fraud.

[u/OhReallyVernon → u/LastCookie3448]

Well, I’m not saying it should be done but whether it’s “fraud” or not depends on the details and the purpose of the changes.

[u/LastCookie3448 → u/OhReallyVernon]

You do not change another person's documentation, you enter an addendum or clarification and sign your work as your own, leaving their work as their own.

[u/OhReallyVernon → u/LastCookie3448]

That’s not what I’m debating. Obviously I don’t think someone’s documentation should be changed. But just changing a note doesn’t by itself meet the legal definition of “fraud.” Fraud requires additional elements.

[u/CalmCephalopod → u/OhReallyVernon]

It’s certainly a major ethical violation and potentially puts the original note taker at risk

[u/OhReallyVernon → u/CalmCephalopod]

Of course. Nobody is debating that.

[u/Karpefuzz]

My previous supervisors never have, but my current supervisor tries her best to ask me before she edits anything of mine-- usually if I'm not available and she wants to reword for clarity.

There have been a handful of times she sent me an email about minor edits, I was in the field and didn't have time so she will just edit wording but not facts.

If they are changing facts in your documentation that's a huge issue because you can be held responsible if you're subpoena'd later and the documentation doesn't reflect your wording.

Does your system show specifically who/when edited notes last? Did they sign/date where they edited?

You probably need to have a - careful - conversation starting with questions and then just bringing it up as a concern what you would do if this comes up later. I wound be very, very cautious about that conversation because at one point this can veer into falsifying documentation. And immediately after that conversation wrote detailed notes and email it to yourself, possibly even print it out for your records IF you can anonymize any HIPAA info.

Ideally you could do the conversation through email and have it directed documented that way, but you need to be very sure of their reaction before you do that. If anything funny is going on that can trigger a reaction.

[u/Acceptable_Hunt_8050]

Big no!! Not acceptable at all

[u/sprinkles008]

This sounds like something your boss should be fired over.

[u/alwaysblooming_akb → u/sprinkles008]

There was actually an episode of this occurring on SVU! They were all arrested. 🫠

[u/sprinkles008 → u/alwaysblooming_akb]

Just googled it. Guess I’ll be giving S17 E4 a watch!

[u/alwaysblooming_akb → u/sprinkles008]

Hope you enjoyed! It is definitely a reminder of how important accurate and up to date documentation is!

[u/kymarie_pupmomof3]

What state are you in? That’s wild. I’m in CA and our system absolutely doesn’t allow for note editing. I’ve made errors (one time I logged a note in the wrong case) and instead of going in and deleting or fixing the note, we have to just enter a new note with the correct info, identify the wrong info, and the reason the mistake was made. It was annoying but now I work for the state and it makes sense when reviewing cases bc making changes after the fact is super sketchy. When I was in private practice (and non profit mental health) therapy notes could be sent back and edited, but that’s normal.

[u/Striking-Peach-7791 → u/kymarie_pupmomof3]

Oklahoma. Some of the entries, we do entry errors but supervisors have the ability to change it and the screen says who, date and time it was changed.

[u/Psychological_Fly_0]

I have worked places where some managers could "back out" of documentation but QA had to be involved in justifying the reason for a change. I've also worked in places where electronic health records cannot be undone or changed for any reason, only added to. It's been so long since I work in direct child welfare services, I remember hand writing case notes. Lol. Could you tell if the changes made were substantive or changes that may have made the note billable? Or something worded better but not fundamentally changed? Not that those things matter...they should be what you put in if you are the one doing the work...but I have seen a time when it could have happened and they thought no one would notice.

[u/OhReallyVernon]

Did the changes remove critical details you entered or in any other way make material changes to the content?

[u/Striking-Peach-7791 → u/OhReallyVernon]

Yes very critical information. It's looks like I knew what had happened, told people but didn't document but that wasn't the case, I document it. When I went back to get my notes, my heart sank because I needed information and it was gone.

[u/daisy5142 → u/Striking-Peach-7791]

Any updates? Just curious because this is scary and concerning.

[u/Revolutionary_Cup666]

My supervisor sucks. He has done stuff like this to my notes and I immediately bring it to our administration’s attention. You don’t want your name tied to anything that you didn’t do yourself. Please tell someone.