PCR REWRITE!?

[Jpostit]

Hello!

So i created this account and finally decided to post after being an EMT for 6 years all because of this situation.

I am working at a new Private ambulance company that started not too long ago. We had started with one PCR format when we first opened and switched to another a few months in. We were all asked to rewrite our old PCRs onto the new format PCR and just simply transfer information.

Now here is where I am having a problem. One of my co workers has quit and never transferred his PCRs. I am being told that because i was his partner and driving at the time that I am able to rewrite is PCRS and fill out his narrative and everything. Is this legal!?!? I feel that because i was not in the back rendering patient care that I should not be writing these things. Ive been told to leave his name on the form as attendant and copy what i can but to add information that the new form requires. Please tell me this is wrong and i should refuse because my gut is telling me thats the case.

any advice would be much appreciated!!!

 

[VentMonkey]

Hello!

So i created this account and finally decided to post after being an EMT for 6 years all because of this situation.

I am working at a new Private ambulance company that started not too long ago. We had started with one PCR format when we first opened and switched to another a few months in. We were all asked to rewrite our old PCRs onto the new format PCR and just simply transfer information.

Now here is where I am having a problem. One of my co workers has quit and never transferred his PCRs. I am being told that because i was his partner and driving at the time that I am able to rewrite is PCRS and fill out his narrative and everything. Is this legal!?!? I feel that because i was not in the back rendering patient care that I should not be writing these things. Ive been told to leave his name on the form as attendant and copy what i can but to add information that the new form requires. Please tell me this is wrong and i should refuse because my gut is telling me thats the case.

any advice would be much appreciated!!!

This sounds highly irregular, follow your gut, and get back to us with the follow up. Good luck.

 

[YoungbloodEMS]

That's either illegal or unethical as ****. I wouldn't do it, but that's just my gut. In the interest of full disclosure I start as an EMT on the 26th so I don't have the experience to guide me, just a moral compass and I wouldn't do it, especially if you weren't rendering the care.

 

[Akulahawk]

Hello!

So i created this account and finally decided to post after being an EMT for 6 years all because of this situation.

I am working at a new Private ambulance company that started not too long ago. We had started with one PCR format when we first opened and switched to another a few months in. We were all asked to rewrite our old PCRs onto the new format PCR and just simply transfer information.

Now here is where I am having a problem. One of my co workers has quit and never transferred his PCRs. I am being told that because i was his partner and driving at the time that I am able to rewrite is PCRS and fill out his narrative and everything. Is this legal!?!? I feel that because i was not in the back rendering patient care that I should not be writing these things. Ive been told to leave his name on the form as attendant and copy what i can but to add information that the new form requires. Please tell me this is wrong and i should refuse because my gut is telling me thats the case.

any advice would be much appreciated!!!

If you re-write any of those old PCRs, you're setting yourself up for potentially massive problems, fraud and/or forgery are among them. About the only way I would even come close to a re-write would be to possibly write whatever I might have direct knowledge as a non-attendant on the new form and attach it to the old one. I would NOT write anything that pertains to care that I did not provide and I wouldn't touch the old one.

Personally, I would refuse to re-write any PCR that I was not an original author of. When I sign my name on the form, I'm attesting that the form is filled out truthfully and as correctly to the best of my ability because... it is a legal document. That record will be sent to whomever needs to review it for billing purposes and reimbursement (from Medicare/Medicaid or other insurance companies). It can become part of a legal process against you, your company, your partner, the patient, or any other entity that "touched" the patient or patient's records during the time covered by that same document. It can exonerate you or bury you.

When I put my name on the form as part of the crew, I am simply attesting that I was a member of the crew.

Now if the new forms require any signatures of people OTHER than original crew, you're up a creek because if YOU showed up at my ED and asked me to sign a new form for a patient that I don't recall... I'm going to refuse to sign that document at the very least.

 

[akflightmedic]

Do not do it.

The company should simply archive the old files and leave it at that. They are original, intact and if any agency conducted an audit, a switch to a new system is easily explained and justified. There is absolutely ZERO reason to rewrite them in the new program. Bad management, bad company...

They would have been better off hiring a few temps to do data entry and kept this off of everyone's radar if they felt that strongly to put data in the new program. I suspect their reasoning is for data analysis and the two programs cannot talk to each other...but they seriously should hire a few temps for a week and let them bang it out.

 

[ERDoc]

Don't do it! I know you don't want to hear it, but look for a new job.

http://www.medscape.com/viewarticle/809517

 

[akflightmedic]

Your link only takes us to a log in page....

 

[ERDoc]

Forgot about having to sign in. Here is a cut and paste.

Question
I work in an operating room, where we have EMRs. We check each other's charts for mistakes, sometimes days later. We are told to make corrections if we find mistakes. Is this legal?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney, Boulder, Colorado

It's good that you are doing internal audits -- staff learn by analyzing what they are doing right and identifying what they need to improve. It is legal to correct mistakes and make late entries, if it is done appropriately. If not done correctly, it could be illegal and, at minimum, more detrimental than helpful.

With your correction, you need to make it clear that the entry is a late entry and that you are correcting a mistake. You should not try to eradicate the erroneous previous entry. You should not try to make the new entry appear to be the original entry. First, know that there may be state laws that apply to this situation. Hospitals should have policies on how to correct errors in the medical record. Your hospital's legal counsel should be in on the discussion about the policy, should review the state law, and should review the policy.

In general, the appropriate way to correct an error is the same as with paper records -- that is, make a new entry with today's date and time, stating that you are correcting an error in a previous entry; give the date and time of the previous entry; and enter the corrected data or explanation. Without knowing the details of your electronic record, I can't say exactly how to accomplish this, but what you want is for the original entry to be visible, with a notation that alerts a reader that this part of the record has been corrected and directing the reader to the corrected information. The original author of the report should be the individual making the correction. If someone else is making the correction, the new author should explain why he or she is making the correction.

The reason for keeping the original entry is that if there is a challenge to the care or the documentation (for example, a lawsuit filed or a claim for reimbursement rejected), the hospital and clinicians need to avoid any indication that the records have been altered in anticipation of litigation or payer audit. Alteration of records (sometimes called "spoliation of the evidence" in a legal proceeding) is detrimental to the defense of a malpractice action or a claim for payment. The opposing party is entitled to an assumption that the altering party had a "consciousness of guilt." Defense attorneys say it is nearly impossible to defend a hospital in a malpractice case when the record has been altered.

A Website for nurse legal consultants tells attorneys to be alert to signs of tampering with medical records. "Tampering with the record involves any of the following: adding to the existing record at a later date without indicating [that] the addition is a late entry, placing inaccurate information into the record, omitting significant facts, dating a record to make it appear as if it were written at an earlier time, rewriting or altering the record, destroying records, or adding to someone else's notes."[1] If records are altered in anticipation of a payer audit, then the payer, when discovering the alteration, presumes the hospital or clinician has billed fraudulently.

The bottom line is that internal audits are good. When mistakes are identified, focus on educating the clinician about his or her error and how to document better in the future. In general, correcting errors found during internal audits should be done rarely and carefully, without intent to deceive.


References

1. MedLeague Support Services, Inc. Detecting tampering with medical records.http://www.medleague.com/services/medical-record-analysis/detecting-tampering-with-medical-records/ Accessed August 1, 2013.
   

 

[NysEms2117]

This is the state that i work in ONLY: http://ypdcrime.com/penal.law/article170.htm
i encourage you to look at article 170.05/ 170.20 && potentially 170.40( if the company\state pros is feeling mean that day). This is just forgery too. This may be "far fetched", but the law can and will stretch. I am providing the law aspect due to the fact i just recently turned into an EMT, but CYA(cover your ***), once you sign your name on those LEGAL DOCUMENTS(permissible in court) they are yours. I could not agree with akulahawk, akflightmedic, and ERDoc more, just providing the actual letter of the law.

 

[Kevinf]

Have you contacted your regional EMS council (if applicable) for input in this situation?

 

[Tigger]

Run away.

 

[Specialized]

That sounds illegal to me. Go with your gut feeling because it is usually right.

 

[twistedMP]

Dude run as fast as you can. I'm guessing some of thr old charts are not billable so their hoping that when you rewrite them they will be billable since you may not remember every detail

Sent from my SM-N930T using Tapatalk

 

[dutemplar]

"Directed by management upon threat of termination of employment to re-write this chart due to EPCR system upgrade and the patient care provider is no longer employed at this company. I am verbatim transcribing the old patient chart. I was functioning as the driver, I have no patient care knowledge and was abjectly mandated to recreate this legal document in spite of having no direct awareness or memory of this patient.

Transcription of original chart follows:"