False Charting

[jjjoy, LPN]

From NancyRN in a thread in the politics/activism forum

Finally, NURSES are going to have to stop FAKING their CHARTING!! I can't count the times I've followed a nurse who charted that she was in a room every 2 hours checking vitals when I know she wasn't. Nurses have to start saying "I didn't get to see that patient for 5 hours because I had too much work to do" and stand together on this issue instead of hanging each other out to dry (I don't know why SHE can't get done...I can!).

I saw this some in the hospital I worked at and A LOT at a LTC facility. There's no foolproof way to ensure that a nurse has done everything just as he/she charted (unless you want to add 24/7 videotaping of each pt room, and in this litigeous society, it's not so unimaginable). And honestly, on a busy day, some things might NOT get done. But how much, really, isn't being done and is still being charted? Of course, almost always these are routine activities that the occassional missing of isn't noticeable. But why should nurses uphold the farce that they ARE doing ALL that they are technically supposed to do and chart? Because if they complain, it won't change. They'll just be told that something's wrong with THEM... everyone else can do it, they don't complain, see how they charted that they did everything just so?

This ISN'T the case everywhere. The hospital I was at was busy and stressed nurses to the limits, but not beyond (for most). The LTC asked for more than was physically possible (4 min/pt to pass meds-adm puffers, eye drops, take BPs, pour meds, crush pills, gently help frail confused pts to swallow a handful of pills, mix fiber drinks, chart as given. Of course, pouring meds ahead of time and charting after passing all meds were against policy, but how else could it be anywhere close to possible without certain shortcuts AND give ALL meds WITHIN THE SPECIFIED TIME FRAME? And god forbid you help a pt up to the bathroom (buzz the aide) or need to take a phone call from a family member during that sprint.

Maybe you're not in the kind of situation. Maybe that's why you're still in nursing. Any thoughts? Be honest.

Folks who say "my job is JUST as impossible, no WORSE, and I CAN DO IT, and anyone who can't shouldn't be a nurse!" need not respond. If everyone were such superpeople, we wouldn't need more nurses, the few could do it all!

[gwenith, BSN, RN]

jjjoy where did you get the quote??

[pickledpepperRN]

I was floated 4 hours into a 12 hour shift. The registry RN who was being sent home had charted for the entire night.

It was 11:00 pm and he had charted vital signs and I&O until 6:00 am!

I called the supervisor who made the nurse a "do not send" but I reported him the to Board of Registered Nursing. Our supervisor promised to do so too.

More than a year later the BRN Report had him listed as "license revoked, falsified medical records."

If there is no time to do required care document who you notified in writing or fill out an "assignment despite objection" or Disclaimer" Date and sign for your record.

I call the physician if something was not done and explain why. If possible I tell the MD before anything is missed.

This usually results in more staff because we have supportive doctors and shift supervisors. (And a good union contract with ADO forms).

[cannoli]

I don't know what isn't being done, I think it is probably assessments. The hospital does computer charting and many people just accept what the previous charting was. Either they are not doing the assessments or not charting them or both. Sometimes I will get accurate info in report, trace edema, for instance, but when I go in to chart, it is still 4 plus edema, which it probably was when the patient was first admitted.

You're right, if you can't get done on time, (I almost never can), there is something wrong with you and you hear about it at eval time. Those people that always or almost always get out on time are not doing something.

[gizzy76]

I can't stand it when people falsely chart. I find things a lot in my LTC facility. I'll have changed a dressing and the previous charting comes up to help you out just incase something hasn't changed. Well, what do I find? That the charting reflects what was SUPPOSED to be on the wound, but what I found on the wound is a completely different story. I don't understand why my co-workers cannot follow some simple directions accordingly. Just my personal beef though.

[elle4pets]

I find that I would do all I could to get everything done for the patient but many times get short changed on the time allotted for the charting of it,

if only I could have a secretary follow me around and document for me like the big wigs in administration wouldn't it be a wonderful world!

[sjoe]

The self-righteousness in this thread is not productive.

The real problem is too few nurses and too many patients and too many demands on the nurses' time.

"Us" (the righteous who always chart exactly--and precisely at the time an act is performed) against "them" (the slugs who do things differently) only serves to perpetuate the "divide and conquer" management strategy that has kept nurses powerless for so long.

IMHO.

And to those whom this post offends, be aware that I or anyone else could look at your work with a magnifying glass and generate outrage at something that you do, don't do, have done, have not done, etc. To do so is not rocket science. Let's work on solving problems, rather than blaming each other.

[cannoli]

I agree entirely with your second sentence.

I do not see any self-righteousness in the above posts.

Are you saying that you agree with false charting?

[Aurora]

I have never charted anything falsely. That's my story and I'm sticking by it.

[elle4pets]

not intending to sound self rightgeous by any means, we asked administration for more help, Lord knows we need it, and guess what they said, we don't have the money, but then a week later they hired a third secretary to sit and greet people who couldn't find administration, so I guess I should have explained the whole situation before I mouthed off.... They could have easily moved one of the other two secretaries up there so they could direct the few people that do get lost ....and gave up the help we really need for patient care!!!!!

[CseMgr1, ASN, RN]

I was doing contract work for an agency a few years ago, when the owner told me to document a supervisory visit on a patient which had not been done, in order that he get paid.

I turned in my notice that very day.

[barefootlady, ADN, RN]

I never false chart. I do my assessments, pass my meds, do orders and dressings , Iv's and attempt to keep an eye on a patient's i/o. Now this does not give me much time for breaks, lunch and I am always assigned count. Sure I get overtime, but I try to protect my license. I know it is a hard job. I know that now every day can or will go smoothly, I just do the best I can and hope that the "nursing angel" will keep her /his eye on me.