NR 599 Week 6 Ethical and Legal Analysis Example

Ethical and Legal Analysis: A Colleague Asks Whether to "Update" a 23:00 Fall Risk Score at 05:30, After the Patient Fell at 03:10

Student Name

College of Nursing, Chamberlain University

NR 599: Nursing Informatics for Advanced Practice

Instructor Name

Month Day, Year

Ethical and Legal Analysis: A Colleague Asks Whether to "Update" a 23:00 Fall Risk Score at 05:30, After the Patient Fell at 03:10

The Situation

At 03:10, an 81-year-old patient on our unit fell while walking to the bathroom alone and sustained a wrist fracture. At 05:30, the patient's night nurse asked me, as charge nurse, whether to "update" the Morse score for 23:00. The 23:00 score in the record was 35, filed with the same answers as the previous three nights. The nurse told me that at 23:00 they had not seen the patient walk and had given zolpidem at 23:15. The nurse now believed the patient's real risk at 23:00 had been higher, and wanted to correct the score to 60 with a service time of 23:00.

The Documentation Act, Placed in Time

The proposed act is an amendment at 05:30 to an entry with a service time of 23:00, after a fall at 03:10 and after the outcome was known. The nurse did not observe the patient walk at 23:00. A score of 60 at 23:00 would be a reconstruction, not a record of an assessment.

What the Record Would Show

Every entry in our record carries two times: the service time the nurse enters and the time the entry is filed, with the user's identity, in the audit log. A score changed at 05:30 to 60 with a service time of 23:00 would show both the original 35 and the change, and the filing time of 05:30, two hours and twenty minutes after the fall. In any later review or lawsuit, the audit log would be produced, and an amendment after the outcome would be read as an attempt to alter the record.

Medicare's hospital conditions require each record entry to be complete, carry its date and time, and be signed off by whoever made it (Condition of Participation: Medical Record Services, 2024). An entry that states a 23:00 assessment that did not happen would not be an accurate record of the time of the act it describes.

A correction made openly is different. A late entry filed at 05:30, labeled as a late entry, stating what the nurse actually knew and did at 23:00, including that the score was filed without observing gait and that zolpidem was given afterward, would show the same audit times and would be consistent with them.

I am not a lawyer, and the hospital's risk management department should be consulted on how such entries are handled.

The Ethical Reading, Built Separately

Setting the legal reading aside, what does the patient, and the nurse, owe and get owed?

The patient is owed an honest account of what happened, including that the risk assessment before the fall was not a true assessment. The ANA code puts the patient's interests ahead of the nurse's own, and nurses answer personally for their own practice, records included (American Nurses Association, 2025, Provisions 2 and 4). Patients and families want to be told about errors and what is being done about them (Gallagher et al., 2003).

The nurse is owed fair treatment. The score was filed in a way many nurses on the unit file it, under a twelve-hour rule that encourages repetition; that is a system problem as much as a personal one.

The unit is owed the truth too: a record showing a score of 60 would teach nothing about why routine scores are repeated without assessment.

Where the Two Duties Disagree

The legal reading points toward minimal change: leave the 23:00 entry as filed, add nothing that could be read as an admission, and let risk management handle disclosure.

The ethical reading points toward full honesty: a late entry stating that the 23:00 score was not based on observation, and a disclosure to the patient and family that includes it.

They disagree on how much to write. A late entry stating that gait was not assessed could be used against the nurse and the hospital. Not writing it leaves a record that implies an assessment that did not happen.

A Chosen Course, and Its Cost

I advised the nurse not to change the 23:00 score. I advised a late entry at 05:30, labeled "Late entry," stating: "At 23:00, Morse score filed without observing gait. Zolpidem 10 mg given at 23:15. Patient found on floor at 03:10." I informed the nursing supervisor and filed an event report, and asked risk management to be involved in disclosure to the family that morning.

The cost: the late entry exposes the nurse, and to some extent the hospital, more than silence would. I accepted that cost because the alternative was a record whose meaning depends on no one reading it closely. The event report names the twelve-hour rule as a contributing factor, so the system's share is recorded alongside the nurse's.

What I Said to the Nurse

I told the nurse that changing the score would make the record less true, not more, and that the audit log would show the change regardless. I said that the late entry would describe what happened at 23:00 honestly and that the event report would name the twelve-hour rule as part of the problem. The nurse was frightened and asked whether they would lose their job. I said I did not know what the review would decide, that I would be honest about the system's part, and that I would be with them when risk management called. That conversation took twenty minutes at 05:35, during the busiest hour of the night, and I asked a float nurse to cover the call lights while we talked.

Disclosure to the Family

At 09:00 the attending physician and the nurse manager met the patient's daughter, with the risk manager. They explained the fall, the wrist fracture and the plan. They said that the fall risk score recorded before the fall had not been based on watching the patient walk and that the patient had received a sleeping medication afterward. The daughter asked whether the score would have changed anything. The manager said a higher score would have put on a bed alarm, which might have alerted staff before the patient reached the bathroom.

What Changed

The case became one of the reasons for the event-driven reassessment proposal, which would have required a score within an hour of the zolpidem.

References

American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/

Condition of Participation: Medical Record Services, 42 C.F.R. § 482.24 (2024).

Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA, 289(8), 1001-1007. https://doi.org/10.1001/jama.289.8.1001