Top Ten Reasons for Being Fired - Falsification of Documentation

madwife2002, BSN, RN

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

Quote
"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"

It is important to remember that falsification of documentation may not only result in the nurse being terminated it is a felony offense and viewed very seriously.

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 Records