The fourth chart had a correction in ink that wasn’t mine, and the date on it was after I had already stopped working. I asked the hospital to explain how a chart could be corrected after my termination and still be used as evidence against me. They said the correction had been made during a routine review, but they couldn’t tell me who had written it. I requested the audit trail for all four charts, including every person who had opened or edited them. That request took another three weeks. When the records finally arrived, three charts had been accessed by someone who wasn’t assigned to my patients.
The audit trail showed that the same nurse had opened all four charts shortly before the termination review. She was the person who had replaced me in the role I had moved into after my hands began shaking. I asked why she had accessed charts belonging to patients she had never treated, and the hospital initially said it was part of a quality review. My attorney asked them to produce the quality-review assignment, and suddenly nobody could find one. Then we discovered the correction on the fourth chart had been entered using another employee’s credentials. The employee denied making it, and the hospital’s own records showed she was off duty that day.
The hospital withdrew the termination and agreed to remove the four charts from my disciplinary file. They also investigated the unauthorized access and the altered documentation, although I never learned exactly who ordered it. I decided not to return to the floor and instead retired after thirty-four years. A month later, the hospital sent me a letter acknowledging that the documentation used in my termination could not be verified as mine. I kept that letter beside my nursing license. They said my handwriting had deteriorated, but when they finally checked the records, the handwriting wasn’t mine at all.
