In the assessment section of our daily flowsheets there is a place to write the "exact time" the assessment was done. Our policy states that every patient will be assessed within an hour of your coming on duty, and that assessments will be charted within 2 hours. When I have 8 patients to assess and the first one I see has some major problem which must be delt with immediately, there is no way I will meet that deadline.(Let alone when the next 2 I assess also have some problems!)
The other night when I sat down very late to chart my assessments I put the time on each assessment as being between 23:30 and 0100, as I always do. It occurred to me that doing this hurts no one except ourselves...and I do not mean the liability of 'falsifying' patient records. I mean that as long as we seem to meet their demands, that they see it as all is well.
Medication is more than an hour late? No problem, just change the administration times. No incident or med variance report...that would just take up more of your valuable time! So the Administration really does not know that your work load is impossible according to their standards.
How can we blame them for believing that staffing is adequate? Looks to them like the work is being done. Go down the standards of care checklist and automatically check that the patient was turned every two hours, then no one will never realize that you spent four solid hours trying to maintain a patients airway while also fighting with the residents to have him moved to the ICU, and there was NO ONE to turn that patient.
I know this is the way it goes day in and day out at my large University Hospital.
It has nothing and everything to do with integrity! We do the best we can for our patients. We prioritize and give nursing care when and where it's most needed. But we never get it all done....and the record rarely reflects that. And much worse, the patient you did not get to may have had a real need that went unmet.
It's a shame, and honestly, I don't know the answer. The other nurses I work with tell me I'm crazy when I suggest that we all do it exactly as adm wants us to...in order to prove that NO...All this work can not be done by one person in 8 hours!
And they are probably right. Because I am not willing to do it their (adm) way. Because it would mean my nursing care and my job would go to...well....you know where.
It's a dangerous game, and I wish we did not have to play it. As long as we "suck it up"
it will never change.
[This message has been edited by Sandygator (edited December 10, 1999).]
Dec 10, '99
I think you may be on to something, and I agree that we should be charting WHEN we are doing things, instead of when they want them to be done. Initially, keeping a log (after work, at home, you'll be wasted I know) for how the shift went and precise documentation of how long you spent with each patient would further back you up.
Let's do it.
Dec 11, '99
I have been doing this for almost a year, in 2 facilities. I was VERY UNpopular in both for it, but I would rather put a circle on a med and explain it was given 2 hours late (for a daily med) and i document the ACTUAL time i am writing something down and add in the times things were done. I have been told that that makes them/me out of compliance. i have respponded with "are you telling me to lie?" with pen over paper.
I am very alone in this, and work with people who can actually get a med pass done on 32 patients in 20 min (NOT!) But when I am asked why I cannot do my job, they site my coworker, and I tell them they do not want me to go there.
I am in a new place, and a couple of us are charting the BULK documentation that does not nessisarily relate to direct care, while some others are doing treatments +/o meds.
I was told when I cannot get something done to do my best, and the shift that follows me has only 2 staff people who complain about having to follow through on work I have started or not been able to start.
But in a word DO IT! if the state can go into your facility and find one case of fraudulent documentation (2 things being done at the exact same time) they can really go to town, and with the new media crusade, we are who will go down in the first few barages, until they learn it is a systems problem.
*** May we all have the serenity to accept what we cannot change, and the determination to change what we cannot accept. ***
Dec 18, '99
what an excellent point you make. I too, however put down the real times I assess someone not make up times. Just for FYI at my facility we do all computer charting and
the computer allows us to change the times to about anything we want (with in 4 hours of the current time) so isnt this encouraging the behavior? I think so.
Dec 29, '99
I too worked in a hospital with outrageous demands on the nursing staff. As far as documenting actual time a task or med was given, if I'd done that I'd be working in Walmart right now. To solve that problem, I did 18 months of research and prioritized my career and life goals. I interviewed at countless hospitals, spoke with the staff and contacted JCAHO. I finally found a facility that met my expectations. I now work on a neur/neurosurg floor night shift with never more than five patients. Yes, five! I have time to not only chart adequately but to actually provide excellent nursing care. True, there are some tough nights but none compare to the other place I worked. If any of you are tired of the panic, contact me and I'll tell you were to find this place!
Dec 29, '99
The facillity in which I am employed, requires the assessment be completed within the first four hours of your shift. I would recommend taking a survey and researching other facillities and then proposing a more reasonable policy. Maybe this is an old policy that has just been reinstated yearly. Anyway bring about awareness and look into becoming a committee member or bring this up to a committee member. Policies can be changed and should reflect the needs of the patient and the institution.
Jan 11, '00
In the small facility in which I work it seems like they play russian roulette with the staff.It's a home for disabled kids and adults with two dozen clients divided into three small homes.Evenig shift is getting stuck alone one of us on and the meds are a HALF HOUR APART IN each house.I don't have enough hands to do the work.We have some more difficult client with feeding tubes and we have several that are supposed to receive one on one for behavior.On top of that we don't have a clerk so we have to update our own charts.Sometimes I feel like I'm working in a lawsuit waiting to happen.I feel like leaving but I love working with the clients and if I could just do the job and not have to worry about the fluff that goes on I would be fine.
Jan 13, '00
Whoa! what ever happened to having your license taken for fraudulent charting? No matter how long it takes to assess your patient, or if the med is late. Chart the time you actually do it, and in the case of the med, explain why its late. I'd rather get called in for giving it late than for falsifying the record.
Where I work, nurses make the policies and protocols. If we see that something is really not working for us we check with outside sources to see what is out there that might work for us.
Hospital type nursing is not going to get any easier, as patients/clients will be sicker, and more demanding. We need to find systems that work for us, not against us. If what we try is not working, look for something else.
Administration says you have to do it a certain way, ask to meet with them and show them what can work better.
To all my fellow workers in the field - may we strive to make a better tomorrow for all of us.
[This message has been edited by Iris in the morning (edited January 13, 2000).]
Jan 31, '00
Absolutely! Chart accurately.
It's scary being the only one to speak up but sinking to the botttom is worse.
I was told I was the only nurse who took so long to finish my paperwork.
I pointed out to the management that I was slow, yes, but look at all the errors I was coming across!
The RN who works faster than I do signs off as having checked things, i.e.recopied med sheets, and then I'm left correcting and documenting their errors too.
Falsifying records is fraud.
You're nuts if you think you will find anyone near you if it is found and addressed.
Feb 1, '00
What a fantasy land. Are you kidding? It is absolutely impossible most of the time to do everything the way it is supposed to be done. I lost my first two jobs by being honest. I would like to meet a nurse who has NEVER falsified records and kept his or her job. I haven't met one yet.
I'd like to believe that I was the only person who has ever done the things I was honest about, but we all know this to not be true. I was going to quit nursing altogether when some more experienced nurses sat down and had a chat with me.
Okay, it's 9:15 and the med was due at 8. Actually 20 other patient's meds were due at 8 too - do I circle them all? I had a patient with acute CHF who HAD to go to the hospital, a full code. If they coded here, the meds wouldn't have been passed till maybe 10, or 11. This is the rule - not the exception. And forget it if the patient was your neighbor! Just stuff all that aside - the meds have got to be passed.
I don't have TIME to argue with the administration and put my license on the line. (More than it in theory is). There is SO MUCH to bring to their attention, and nobody would ever get cared for and what would happen, but you know what hitting the fan. Why bother?!!
I see your point about bringing it to the attention of the administration, but I can only be so altruistic, and who is going to stand behind me? Not my coworkers! You see, we would all have to be willing to be martyrs at the same time for it to work, and that would be like trying to get every molecule in a brick to jump at the same time. Good luck! I've worked in 4 LTC facilities now, and it hasn't worked for me. I may end up in Walmart yet, myself...
Feb 1, '00
I can sympathize from the management side of the hospital. Staffing gets tighter and tighter due to budgets, etc. But, I also believe that you need to chart when you complete a task. If your policies are not realistic, have a team look at them. Sometimes policies and procedures just get reviewed year after year and do not really reflect what is going on on the nursing units. In our hospital, days and evenings do a complete assessment once per shift, and night shift completes an visual assessment if the patient is sleeping, but a more complex assessment if the patient is really ill. Our physicians do not want their patients awaken on night shift for a complex assessment, unless they are really critically ill. This rule, of course applies to the med/surg units. Our hospital emphasis' is always placed on timely assessments and accurate charting. Good luck with your problems - but it really is a process, not a people problem.
Feb 17, '00
In my opinion the reason things can't being done in a timely manner (according to policy)is because of the fact so many facilities are understaffed. Perhaps if we would all stick together...charting things when they were actually done, instead of when policy states it should be done, administrations would see that to give quality care in a timely manner that there as to be ampule staffing. I've been a nurse for almost 6 yrs, I've worked home health, geriatric nursing and corrections, seems every where the complaint is the same...under staffed, over worked and NEVER enough time to get everything done that's expected to be done in the hours alloted for your shift.
False documentation is a serious crime, it could cost you your license and administration that encourages it aren't looking out for you, but only wanting to make themselves look good by being in compliance.
Let's start documenting times correctly, covering our own butts and perhaps we will see changes in our field.
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