What constitutes falsifying documentation?
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This is a discussion on What constitutes falsifying documentation? in General Nursing Discussion, part of General Nursing ... I know of a nurse who put her initials on a flow sheet for her entire shift ahead of time. She was...
by physioex Aug 13, '10I know of a nurse who put her initials on a flow sheet for her entire shift ahead of time. She was in orientation and was never told by preceptor or coworkers that this constituted falsification of documentation. She was terminated for doing it on 3 occasions. She never falsified assessments, v/s, outcomes, plans of care, only initialed her flowsheet for her entire shift before it was actually that time. She'd been complaining of coworkers being viscious, making false accusations, and tattle telling about non-nursing related matters. She'd had felt like she was being watched closely to get fired and now it came true!! Can she really be terminated for this? Is this really falsification if she did the actually charting at the real time, but only initialed ahead of time?
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Aug 13, '10 by Spritenurse1210I'm sorry to hear about your coworker. I don't see how just putting your initials on the flow sheet constitutes falsifying documentation. I may be wrong.mskate likes this. -
Aug 13, '10 by Hospice Nurse LPNIt is falsification. What if something happened and the pt died or was sent to the hosp or went on pass with family? What if the nurse had to leave her shift early? How would she explain documenting those items? I used to work with a nurse who signed her entire MAR/TAR before a.m. med pass. It's just wrong. - Aug 13, '10 by Flying ICU RNcan she really be terminated for this? is this really falsification if she did the actually charting at the real time, but only initialed ahead of time?
in a word,.. absolutely.
what may seem a minor transgression in documentation by an individual, calls into question the entire treatment record and by default, the institution’s “covenant of public trust.” -
Aug 13, '10 by pielęgniarkaYes it is falsification, I was taught this is a big no-no. The initials signal that the task was completed. Where I work you cannot sign for anything until it is completed. MARs (med admin record) get initialed after the meds are given. TARs (treat. admin record) get initialed after the treatments are completed. -
Aug 13, '10 by RN1980its just bad form and practice to do this. the med record and tx record are there not only for other staff members to see what meds/treatments have been done and when they were completed, but it also serves you as a reminder of what was completed and what is not. just think at the end of a busy day you look at your med or tx record and you have initialed everything before hand you could have actually overlooked a med or tx but since you intialed it earlier you'll never know. this is a bad practice for all you younger nurses out there. beware.... - Aug 13, '10 by MsbossyRNI'm just surprised she wasn't told the first time she did it, that it was wrong. I am sure if she were told she was not to do it, they could have avoid firing her.
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Aug 13, '10 by Asystole RN$1,000 says that she was not terminated for what was described.
The falsifying docs was the excuse (the paper trail) used to remove her. She was either doing something else that was difficult for leadership to officially remove her for or she rubbed the wrong person the wrong way. - Aug 13, '10 by roser13"a nurse who put her initials on a flow sheet for her entire shift ahead of time"
"Ahead of time" is all that needs to be said. Anyone who signs their name to documentation that doesn't correlate to real time is asking for trouble.
No question at all.Last edit by roser13 on Aug 13, '10 -
