Creating and signing a document under my name...

[Guest ERCat]

Today while at work I got a call from the clerk stating that a patient was on the phone with questions about a prescription that was I called in for them. I looked up the patient and was shocked to see that three hours ago I personally wrote a note in the chart that I followed up on her culture results and prescribed an antibiotic. I was shocked and actually a little bit spooked because the note was NOT written by me but it clearly said it was written by me and had my electronic signature. I was so confused I asked the woman if I could call her back. I realized one of the doctors I work with often does cultures close to my work station and called him. I asked him if he did cultures today and he said yes, and didn’t mention anything about the chart. Then I told him what happened and that I felt he put a document in my name as the author with my signature and he said, “Yeah, I meant to tell you about that. You were already logged in and I didn’t want to log in on a different computer so I just put the culture follow up.” The vibe I got is that this was not a mistake, that it was done out of convenience and that it’s “just a culture follow up” and “just a prescription for an antibiotic.” I asked him to write an addendum on the chart and also found a way to cross everything out on the note as an error. He seemed surprised I was anxious about it but I didn’t let on how upset I was.

I don’t know if I am overreacting but I feel extremely violated and spooked about this. First of all the antibiotic called in was very inappropriate in my opinion. It is unclear if the prescription also went in under my name but regardless, the note states that I prescribed this antibiotic which has a notorious reaction for causing severe and sometimes fatal side effects in combination with another medication she was on (the doc knew about this interaction and wasn’t phased). The antibiotic choice was the least of my worries if the doc felt it was OK. What upsets me is that there was a document created under my account and SIGNED by ME - a legal document. And I would have had NO WAY OF KNOWING if the lady hadn’t called wirh questions. It makes me shudder to think that if the lady had an adverse reaction to the antibiotic combined wirh her other meds and it was documented in the chart that I was involved, that I would be sued and I would have NO PROOF that it wasn’t me.

Again, I feel violated and not sure how to proceed. I tried to let this go but I still feel very upset about it.

[SedRate]

I always make sure to sign out each time I leave the computer. It's a legal document. Offer to copy and paste the note appropriately under his account to correct the issue. Although you shouldn't have to since it was he who used your account, at least this insures you that it has been corrected. Then, mark your note in error and why. 

[ventana]

really uncool for the doc to have done

 

you have TOTAL control over this.  Log out each and every time, change your password, and never share it... problem solved

 

I would likely follow up with this doc via email (for the record) and simply state you would appreciate it if he would not make chart entries under your name

In the official chart I would put a single addendum that stated "above chart note entered by Dr SoSo"

[mgriffiths]

13 hours ago, ventana said:

really uncool for the doc to have done

Not just uncool - absolute fraud.  Whether the computer was left logged in (obviously should not have been, but separate topic - regarding HIPAA laws) the doc purposefully put in an order under someone else's account and then signed off as this other person.  That is the definition of fraud and without question is grounds for dismissal from whatever position that individual has and potentially even loss of medical license.  I'm not saying it HAS to go that far, but this is more than uncool...

[Guest ERCat]

21 minutes ago, mgriffiths said:

Not just uncool - absolute fraud.  Whether the computer was left logged in (obviously should not have been, but separate topic - regarding HIPAA laws) the doc purposefully put in an order under someone else's account and then signed off as this other person.  That is the definition of fraud and without question is grounds for dismissal from whatever position that individual has and potentially even loss of medical license.  I'm not saying it HAS to go that far, but this is more than uncool...

Exactly...

 So I am aware that a computer should not be left logged in. We were told that in training. Don’t know if this makes it any better but this was in my personal office where only I sit. I will be honest, not even one provider or nurse or tech in the entire ER logs out every time they leave their work station.  In the shift I could walk back-and-forth from my desk over one hundred times a day. That would mean  logging in and out of my computer one hundred times which would very much hurt my efficiency.  The reason being, It takes about two minutes to log back into everything. Perhaps I will talk to IS about how to expedite this process. Maybe I could link the log in with my badge so I just have to swipe my badge to save time...

But yes, your post is more along the lines of the reaction I was expecting. To me this is fraud and maybe I am taking it too seriously, but this could be grounds for termination (although it would mean I and every other provider and nurse in the ER would have grounds for being fired because we all leave our computers open all day). On an ethical level it’s also just a sleazy thing to do especially as it wasn’t accidental and was done because he was too lazy to log in to his own computer.