Top ten reasons for being fired - Falsification of Documentation
If you didn't document it, you didn't do it! This is a statement most nurses live by! Unfortunately there are nurses who document things they didn't do, which may result in harm or neglect to a patient. Subsequently this may lead to felony charges of falsifying medical records. Fines of up $25000 and 5 years in prison can occur if proven by documentation specialists. So not only could you lose your job, your license, you could lose your liberty.Falsification of documentation is number 6 on the list of 'Ten reasons why we get fired'
Documentation is a large part of a nurse's daily routine; everything we do, say or plan has to be documented. The greatest nurses saying has to be 'If you didn't document it, you didn't do it' this means we spend half if not more of the day documenting.
When I was training to be a nurse we were taught to assess, plan, implement and reassess. We were expected to document in the same manner, also providing the rationale to everything.
Today language may have changed but the basic principles are the same.
You should not document something you didn't do, for example if dispensing a medication to a patient you should not sign off on that medication until you have seen the patient take the med. There have been cases where RN's have signed off on medication yet the patient never received the med. This could have been due to genuine mistake or deliberate action.
Medications take a great deal of time out of the day; nursing is a fast pace environment and sometimes medications get missed. In some nursing environments if you are late or miss a medication there is potential to get disciplined, sometimes this results in nurses signing off on the medication and disposing of it so they do not get into trouble. This is falsification of documentation.
Another example of falsification of documentation is signing off saying you have completed something for the patient, it is either documented early before you have actually done it, or in rare cases something you have no intention of completing. You may have every intention of doing what you have documented but time runs away and it is not done. It is not best demonstrated practice to document in advance that you have completed a task when you have not done it! Do not document in advance, you may think you are saving time but in reality it is falsification of documentation. It is a bad habit and you need to stop: you will be terminated for falsification of documentation and reported to the BON.
Computer charting is able to detect actual time you documented, even when you change the time to fit in with your documentation there is a time stamp, so if a computer expert goes in to find out times and changes in the patients documentation they can pinpoint the actual time the information was documented. Remember if you are documenting late, always acknowledge this by stating "written in retrospect". Do not try to cover anything up! Everything is discoverable.
For example you state that a medication was given at 0715am, the pyxis dispenser shows the medication was actually dispensed at 0830am. Yet in your documentation you state the medication was given on time.
With paper charting is can be easier to detect falsification, if paperwork is missing then guilt is presumed. If you paper chart and make an error, draw a line through the error then date and initial. Medical experts will scrutinize the handwriting looking for differences, different ink used for alterations which are not done following correct procedure. Never leave a blank space when paper charting, if another nurse needs to complete her documentation they need to do so in retrospect. Leaving a blank space allows for falsification of documentation, unknowingly causing you to be a co-defendant.
These examples are things that occur daily in the hospital, they are not rare occurrences, nine times out of ten nobody notices, nothing disastrous occurs. It is not until something goes horribly wrong do we panic, overthink the situation and then make poor judgments.
In PA an LPN was prosecuted for taking a verbal order and transcribing it incorrectly, she was not prosecuted for the patients demise but for falsifying documentation
"Relevant Alleged Facts In this first case of its kind in the nation, an LPN working in a Pennsylvania nursing home has been criminally charged with attempting to cover up a medication transcription error regarding a resident who later died.
The resident was admitted to the nursing home 4 weeks before her death. Allegedly during the resident's stay, the LPN received a verbal order to reduce the resident's anticoagulant medication. A short time thereafter, the resident's condition worsened, and the LPN realized that she failed to transcribe accurately the order to reduce the anticoagulant medication. The LPN then allegedly falsified the resident's medical record to indicate that the physician order had been implemented correctly. It was this alleged falsification of the medical record, not the initial error itself, which formed the basis for the criminal charges"
If you need to add or change previous documentation, you should not attempt to eliminate previous documentation but add to it by using the current time and it is suffice to acknowledge it is a late entry. The legal world knows that situations occur causing health care professionals to document in retrospect. What is not acceptable are attempts to cover up previous documentation.
Nurses must remember that the medical record is a legal document, and be very respectful of the power of their documentation.
Falsification of Medical Records
Detecting Tampering with Medical RecordsLast edit by Joe V on Dec 9, '13
About madwife2002, BSN, RN
madwife2002 has '24' year(s) of experience and specializes in 'RN, RM, BSN'. From 'Ohio'; Joined Jan '05; Posts: 9,698; Likes: 5,350.
Must Read Topics0Dec 9, '13 by madwife2002, BSN, RN Senior ModeratorQuote from 0.adamantiteSo if I do a dressing change at 2000, but don't document it until I get time at 2300, I need to put 'late entry?' I'm just clarifying, because many times I won't document my assessments until many hours after I did them.
Yes it is fine to document late as long as you acknowledge it1Dec 10, '13 by marshmallownurseHere's a question: it's pretty damn hard to fake documentation time with electronic documentation softwares. It's so close to impossible that I've been assuming that I don't need to point out that I'm doing a late entry. Pulling up the medical record will show two things: (1) the time I documented an intervention; and (2) the time I'm saying I actually did the intervention. I assume that my intent, ie. retrospective documentation, is pretty obvious and I am not hiding anything. Have I been doing things incorrectly this whole time?0Dec 10, '13 by madwife2002, BSN, RN Senior ModeratorTo clarify when doing your charting in the EMR regarding the normal day to day care of the patient you are looking after you should complete the documentation before the end of the shift. (remember check your facilities P&P to double check)
With this being said, BDP is to document as soon as you can in your shift. Normal practice is within one hour
If there is an unusual occurance you need to use the exact times that this occurance happened when you document.
If you give a medication late-you need to acknowledge that. Your hospital will have guidelines of how early or how late you can administer the patients medications, usually within the hour of the time. Some hospitals have tighter rules and it can be 30 mins either way. You will have to check.
Normally nurses are not out to commit fraud-fraud tends to be a concious decision.Last edit by madwife2002 on Dec 10, '130Dec 10, '13 by madwife2002, BSN, RN Senior ModeratorYou are correct it is pretty damn hard to fake EMR's but it can be done and people will try. No you are not doing it incorrectly.
the hospital is at risk if the patient has a bad outcome and sues. The standard is that documentation be completed within 1 hour of making an assessment or administering a treatment, unless an order calls for very frequent assessments or treatments or unless hospital policy states otherwise. If the documentation isn't timely, a plaintiff's attorney is likely to argue that the documentation isn't credible, which hurts the hospital's defense if the hospital is sued0Dec 10, '13 by trishmsnQuote from 0.adamantiteNo, you time the documentation when it is written, and note the action when it occured" Juneteenth 1st, 2035, 2310: Drsg right knee changed at 2008 [describe drsg change]. ......." sign!So if I do a dressing change at 2000, but don't document it until I get time at 2300, I need to put 'late entry?' I'm just clarifying, because many times I won't document my assessments until many hours after I did them.0Dec 11, '13 by gonzo1Our hospital has a scan system for giving meds. First you scan the meds, then scan the patient, and hit enter so technically you have scanned that the meds have been given before the pt swallows them. So isn't that fraud? Sometimes a pt spits them out or they fall on the floor or something. So then I go back and chart that the med was damaged while being given.....Is there any other way to do this so I am not charting that I gave meds before I give them?