False documentation... more common than you think. - page 10
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... Read More
5Apr 30, '12 by CapeCodMermaid, RNHere 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.
0Sep 12, '12 by hotflashion, BSN, RNInteresting 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
0Oct 1, '12 by *4!#6I 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.