False documentation... more common than you think. - page 10

by OnlybyHisgraceRN | 25,378 Views | 94 Comments

Disclaimer: This is my personal opinion and I hope we can agree to disagree if need be. If you are a perfect nurse, please do not read. I have seen many threads on AN about false documentation and while most replies to these... Read More


  1. 0
    Quote from bagladyrn
    You do not know me nor do you work with me (or I'd assume most of the other posters here) so I'd suggest you refrain from stating what you think I or they would do as fact and accusing us of hypocrisy.
    Speak for and be responsible for your own actions only.
    Notice the post was started "I would be willing to bet..." She didn't state it as a fact.

    Your suggestion is noted. And moot. The freedom of others to express their opinions is in no way affected by your hurt feelings.

    If it bothers you that much, I suggest you stop reading and find something else to do.

    See how pointless the suggestion game is?
  2. 5
    Here is what I perceive to be the problem here: if I post on here that I've made a multitude of mistakes I will most likely be told it wasn't my fault. It was the short staff or the work load or someone else's fault.But if I come here and post that I don't ever falsify a medical record, I get called a hypocrite, a liar, and told that I think I'm perfect.Something really wrong with that picture.
    bagladyrn, psu_213, sapphire18, and 2 others like this.
  3. 0
    Interesting topic. Kind of old, but I have a reason to be here reading about it. In the 2 places I've worked where there was charting on a MAR, at the end of every month, one of us nurses checks each MAR: finds the holes, refers to schedules to see who was on duty that shift, flags it for that nurse to sign before it is put into the chart. I know that sometimes the nurse doing the checking has just initialed it, either with his/her own intials or with the initials of the one who was on shift.

    This is false charting, but done as a matter of course. I assume this is done so that when the charts are audited, there are no holes. It makes me think that my signing at the actual time of medication administration is meaningless. I do not condone it, and I've not spoken up about it, but I'm getting ready to speak up and not because I want to but because I have to. I'm stuck between a rock and hard place and (to mix metaphors) I've got jam on my nose.

    Is this a practice any of you are familiar with?
    Last edit by hotflashion on Sep 12, '12 : Reason: to add a question
  4. 0
    Really, is this common practice? I'd like to know.
  5. 0
    I do my best to be 100% honest with my charting. Even with the meds. With 4 patients on a busy unit, day shift, all who have fifty bajillion meds due at 8am, at least one of those patients may get their meds after 9 am. My assessments are always done before 9am. But I always chart the correct times for each med and for assessments/treatments. If I realized I forgot something such as examining that skin tear on patient A's right arm, I go back to look at it at another time before I chart on it.


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