Wiki med sheets

[alices]

Good morning everyone I hoping someone can answer this question on facility side of the er, we have med sheets that lately the nurses have been writing down the stop times on the 2nd pg which is a carbon copy of the original, is that leagal, do they need to get the originals and write them on there?
they have been doing that because sometimes they forget to write on the original and it comes to us before they can catch them, so can they do that and if so or no is there somewhere I can find it in writing, I really can use some guidance on this issue..all the help is appreciated...thank you, alice

 

[TonyaMichelle]

A copy is a copy and an original is an original, so if the nurses are recording information on a copy of the original and the same recorded information is missing from the original copy, that would be fraudulent documentation due to that information being missing from the patient's chart.

If the nurse just happen to remember some time later that she forgot to document something, she must go to the original copy or a separate and new original document and record the information that she forgot to record and title that information as a "Late entry" for whatever date that entry is intended for and sign and date that entry with the date she remembered to document.