Question

You have observed an LPN with whom your work in a clinic attempting to erase an entry she has made in a patient’s paper medical record. She asks you not to tell that you saw her attempting to erase the entry. What do you do next?

Answer 1

Observing an LPN attempting to erase a medical record entry is a serious concern that must be reported through the correct chain of command, upholding the healthcare field's ethical standards on accurate documentation.

Step-by-step explanation:

When you observe an LPN trying to erase an entry in a patient’s paper medical record and asking you to keep it a secret, it is a serious matter that needs to be addressed professionally. In most healthcare facilities, altering patient records is against policy and can have legal implications. It is important to handle the situation through the appropriate chain of command within the facility. This would typically involve reporting the incident to your immediate supervisor or the clinical manager, while ensuring that the report is factual and without bias. The integrity of medical records is paramount, and any attempt to modify them inappropriately puts patient care and the facility's operations at risk. Therefore, one must adhere to the ethical standards of the healthcare profession, which emphasize the importance of honest and accurate documentation.