u/ghost15324

So I made a post recently about accidentally leaving part of my template in a refusal PCR that should not have been there. The patient refused vitals, but I left in lines like “vitals stable,” “lungs clear equal bilaterally,” and “abdomen soft and non-tender x4” from the template.

I’m planning to talk to my supervisor and figure out how to either edit it or add an addendum so the chart is accurate.

The only issue is this happened about a week ago, so I’m not sure how that usually works once a PCR has already been submitted and uploaded.

Can supervisors still reopen it for editing or add an addendum after that long? How does your agency usually handle situations like this?

I had a call recently where I could see the patient potentially ending up in court, and after I got home I realized I may have left part of my preset template in my PCR. I documented that the patient refused vitals, but later in the second paragraph it still says things like “vitals stable, lungs clear equal bilateral, abdomen soft and non tender x4,” etc.

I’m new and only have about 2 months on the job, so I’m worried if the patient ever ends up in court and I get called as a witness, lawyers would pick apart the inconsistency in my narrative. Has anyone dealt with something like this before? Just really paranoid about getting in trouble so if someone can ease my nerves I would appreciate it lol. Thanks in advance guys!