False Documentation

[Daytona.67]

I am an LPN and I have a question about false documentation. I know it is illegal to chart ahead on a patient. My question is this...When your supervisor comes to you and says that some nursing assessments and progress notes are missing on certain days. They tell you to go back to that specific date and see if you were working. If you were and it was your patient that day, do your assessment and progress note for that day. Would this be considered "false documentation" since the documentation isn't done in real time? How can you document on a patient you haven't assessed in 3-4 days and put accurate information? I am worried about this since a nurse was recently fired for false documentation.

[lindarn]

I would be making a complaint to the Labor Board. But that is just me.

JMHO and my NY $0.02

Lindarn, RN, BSN, CCRN (ret)

Somewhere in the PACNW

[toomuchbaloney]

I have been told on more than one occasion by my employer that I am required to finish charting on my own time. This even came up during the hiring process. Based on the fact that I needed a job, I complied with the employer's demands. Do I recommend it, of course not. But I have seen plenty of other nurses who needed their jobs too.

I have been told that as well.

I do not work off the clock for my employers as a rule. I am a paid employee not a volunteer. In my view, our documentation is very important and protects us, the patients, and the facility. I prioritize it high on my list of things to do rather than low on the list. I can delegate many many other things but I cannot delegate that.

If I were being expected to work off of the clock and made to fear losing my job if I didn't comply I would be testing them and formally complaining to the appropriate people. While I too need my job, I refuse to participate in those type of shenanigans.

Good luck.

[Here.I.Stand, BSN, RN]

I have been told on more than one occasion by my employer that I am required to finish charting on my own time. This even came up during the hiring process. Based on the fact that I needed a job, I complied with the employer's demands. Do I recommend it, of course not. But I have seen plenty of other nurses who needed their jobs too.

Their demand is illegal, and I'm sure your employer's legal department would have something to say about it. The federal Dept. of Labor does! In fact, not only are they required to pay you, but if the hours qualify for OT, they're required to pay OT.

Fact Sheet - Wage and Hour Division (WHD) - U.S. Department of Labor

Unauthorized Hours Worked

Employees must be paid for work suffered or permitted” by the employer even if the employer does not specifically authorize the work. If the employer knows or has reason to believe that the employee is continuing to work, the time is considered hours worked. See Regulation 29 CFR 785.11.

Example #13:

A residential care facility pays its nurses an hourly rate. Sometimes the residential care facility is short staffed and the nurses stay beyond their scheduled shift to work on patients' charts. This results in the nurses working overtime. The director of nursing knows additional time is being worked, but believes no overtime is due because the nurses did not obtain prior authorization to work the additional hours as required by company policy. Is this correct? No. The nurses must be paid time-and-one-half for all FLSA overtime hours worked.

[TriciaJ, RN]

When we kindly agree to chart or do anything else off the clock, we are willing participants in a corrupt system. No employer is to require anyone to work for free, and charting is not optional. This is a dilemma for individual nurses; we need our jobs. If our coworkers don't want to rock the boat, we are all perpetuating a system that's going to impact nurses and their families for decades to come.

We really need to get better at standing up for ourselves and each other. Unfortunately, most nursing schools don't even mention labour relations, let alone teach this as a course. So every nurse ends up fending for him/herself.

[morte, LPN, LVN]

accessing patient info off the clock is a HIPAA violation.

[toomuchbaloney]

accessing patient info off the clock is a HIPAA violation.

That is correct.

AND...

when we are off the clock we are not provided ANY of the protections that our employment might offer, as has been pointed out (workers comp, etc)

[dream'n, BSN, RN]

In almost every job I've ever had, I've heard the whole NO OVERTIME speech given to staff. I've heard it over, and over, and over again. Yet I very often have to stay over to chart, etc. and I have NEVER clocked out while doing it. No one has ever said a word to me about it and I've never seen anyone fired for it. I've often wondered if the no overtime speech is just used as some type of scare tactic for nurses that will try to milk the system? All I know is that if I have to stay and finish, I do so on the clock, but I make sure that I'm honestly working hard to finish, not using it as a gimmick to earn more money. Plus I guess my coworkers and bosses know that I'd rather get the heck out than stay to earn a little extra.

[Libby1987]

I can't speak to the off the clock issue as I'm not paid that way, but why wouldn't a nurse have important notes written on something that can later be transcribed onto the without documenting false information?