False documentation... more common than you think. - page 4

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

  1. Visit  Horseshoe profile page
    0
    Quote from Ladybluebell
    I think everyone does some "creative' charting once in a wile with the workload we have, and manager's breathing down your neck. I would never make up vital signs or anything, but sometimes you need to get creative. I will document hourly rounds because i am expected to, but sometimes i might not really get in to the room that often. I don't consider this as false documentation. If i am in the room q2 instead of hourly and the patient is ok, whats the harm.
    Of course it is. If it's not true, it by definition must be false.

    There may be no harm in a q 2h check. If you can justify it due to the patient's condition/status, by all means chart a q 2h check.
  2. Visit  Horseshoe profile page
    0
    Quote from PediLove2147
    If I do a neuro check (we do them Q4H) at 12PM but do not get a chance to chart until 3PM, is it "false documentation" if I change the time to reflect when I did the actual assessment?
    Can't you just write "late entry-neuro check at 12 pm shows patient is alert and oriented x 4," etc.?
  3. Visit  Teacher Sue profile page
    0
    With more institutions moving to an electtronic Medical Record, it is becoming increasingly difficult to document "creatively." Although in most EMRs you can go back to an earlier time, the charting will still reflect the actual time the entry was made in the chart. So if you do all of your charting at the end of the shift, you can document those hourly checks on time, but anyone reviewing the chart will see that you did all of your documentation at one time. Our hospital has gotten around this by allowing an explanation for this in the progress notes. We write something like, "Hourly checks done as ordered, documented at..." Of course, we are expected to do what we charted, or we will be looking for a new employer.
  4. Visit  Teacher Sue profile page
    3
    Mindlor, you seem to think that every problem with our healthcare system is created by management. I never knew there were so many greedy, evil people in our country who want to make patients sicker and make nurses unhappy just because they think it's a cool thing to do.

    Quote from mindlor
    I really think nurses want to do right.....

    I will blame the employers for driving this.

    They must give us more time to do our work........
    GrnTea, CapeCodMermaid, and Vespertinas like this.
  5. Visit  Been there,done that profile page
    9
    Quote from Teacher Sue
    With more institutions moving to an electtronic Medical Record, it is becoming increasingly difficult to document "creatively." Although in most EMRs you can go back to an earlier time, the charting will still reflect the actual time the entry was made in the chart. So if you do all of your charting at the end of the shift, you can document those hourly checks on time, but anyone reviewing the chart will see that you did all of your documentation at one time. Our hospital has gotten around this by allowing an explanation for this in the progress notes. We write something like, "Hourly checks done as ordered, documented at..." Of course, we are expected to do what we charted, or we will be looking for a new employer.
    I work in a large metropolitan medical center. The manager has deemed that our main assessment be done and charted within 2 hours of our shift start time.
    Sooo.. I start at 3:00, sometimes need to hunt down several nurses .. running around , trying to get things done so they can go home.

    It's not unusual to take until 4:00 to get report.

    Then I must assess 6-7 patients. How in the h*ll can I even accomplish that.. let alone enter them into the EMR? Those first 3 hours consist of running around .. eyeballing my patients and putting out fires.

    In the perfect world of management dreams... I could leisurely stroll into each room. introduce myself.. fill out the all important white board.. do 6 or7 complete physical exams and chart them.
    That is of course.. unless one of those 6 or 7 patients might actually ...gasp.. need something!

    You bet I falsely document... I am aware that the actual time I enter anything in the EMR is noted.

    Perhaps some of the "watchers" could stop watching .. and help deliver patient care?
  6. Visit  WeepingAngel profile page
    1
    Quote from Been there,done that
    I work in a large metropolitan medical center. The manager has deemed that our main assessment be done and charted within 2 hours of our shift start time.
    Sooo.. I start at 3:00, sometimes need to hunt down several nurses .. running around , trying to get things done so they can go home.

    It's not unusual to take until 4:00 to get report.

    Then I must assess 6-7 patients. How in the h*ll can I even accomplish that.. let alone enter them into the EMR? Those first 3 hours consist of running around .. eyeballing my patients and putting out fires.

    In the perfect world of management dreams... I could leisurely stroll into each room. introduce myself.. fill out the all important white board.. do 6 or7 complete physical exams and chart them.
    That is of course.. unless one of those 6 or 7 patients might actually ...gasp.. need something!

    You bet I falsely document... I am aware that the actual time I enter anything in the EMR is noted.

    Perhaps some of the "watchers" could stop watching .. and help deliver patient care?
    OMG. I assess everyone within two hours, but if I had to actually document all of those assessments (each and every shift) within two hours, well I just don't know how I'd do it. Sometimes I get in at 7pm and can't get assessments and notes into the computer until 11 or 11:30 pm. Jeeeeez.
    Aurora77 likes this.
  7. Visit  PediLove2147 profile page
    3
    Quote from Horseshoe

    Can't you just write "late entry-neuro check at 12 pm shows patient is alert and oriented x 4," etc.?
    It is a pull down assessment, you can do a comment though. But I don't see the point of writing that it is a late entry, I did the assessment at 12. It is not like I am making an assessment up, at which point I would consider false documentation coming into play.
    wooh, CompleteUnknown, and KelRN215 like this.
  8. Visit  OnlybyHisgraceRN profile page
    0
    Quote from PediLove2147
    It is a pull down assessment, you can do a comment though. But I don't see the point of writing that it is a late entry, I did the assessment at 12. It is not like I am making an assessment up, at which point I would consider false documentation coming into play.
    I guess I was misunderstood. What I meant was, there was many times when neurochecks q15 min cannot be done EXACTLY q15 min and is still documented as if it was done "on time".
  9. Visit  CapeCodMermaid profile page
    8
    There is a difference between charting something that you've actually done and charting something that you didn't do.
    If I actually assess the patient at 10am but don't chart it till 230 that is not false documentation. If, on the other hand, I sign off everything in the treatment book as done but never once left my chair at the nurses' station, that IS false documentation. I'm sorry all y'all have such rotten managers. Perhaps they've never had your job and don't really know is a policy or protocol is realistic.
    We've changed many of our protocols and policies to reflect real life. It is impossible to toilet 40 residents every 2 hours so why chart that you are? We customize our care based on what the resident needs so the work gets done and the charting is valid.
    PS.I am managment and I've had all your jobs at one time or other. I don't ask the nurses to falsify documentation. We don't hide mistakes since many times they are caused by a systems problem.
  10. Visit  wooh profile page
    2
    Quote from HalfMarathoner
    OMG. I assess everyone within two hours, but if I had to actually document all of those assessments (each and every shift) within two hours, well I just don't know how I'd do it. Sometimes I get in at 7pm and can't get assessments and notes into the computer until 11 or 11:30 pm. Jeeeeez.
    One of my coworkers this morning had a column pulled up for 2045. At 0800. We're supposed to clock out at 0715. And yet she was still charting. And I was still there to see her charting.
    WeepingAngel and Sisyphus like this.
  11. Visit  Horseshoe profile page
    0
    Quote from OnlybyHisgraceRN
    I guess I was misunderstood. What I meant was, there was many times when neurochecks q15 min cannot be done EXACTLY q15 min and is still documented as if it was done "on time".
    Well, then from a strict factual point of view, that is indeed false documentation.

    If it's not true, it's false.
  12. Visit  mindlor profile page
    0
    Quote from Teacher Sue
    Mindlor, you seem to think that every problem with our healthcare system is created by management. I never knew there were so many greedy, evil people in our country who want to make patients sicker and make nurses unhappy just because they think it's a cool thing to do.
    I beg your pardon? I am sitting here befuddled trying to make sense of your post......

    Can you please explain?

    It almost seems like a veiled personal affront.....
  13. Visit  psu_213 profile page
    0
    Quote from Been there,done that
    At the onset, when administrative bureaucracy came up with the requirement to document :

    Q 15' checks for ANYTHING

    Q 2 hour checks for restrained patients... checking the restraint site, checking the toileting needs, checking the need for continued restraints, checking the vital signs...

    We unanimously agreed...

    They are MAKING us lie! The very act of initialing all of their precious little boxes .. makes it too time consuming to perform the tasks!
    This is not just LTC... it is everywhere.
    Any one that doesn't see that .. has their head buried in the sand.
    Kudos to you for having the guts to bring this issue into the real world.
    I have an issue with the 'making us lie' part. The policy (law?) is to do restraint checks q2h for some restraints (q15 min for others). If I just fill out the form (for us, a check box form on the computer) without actually monitoring all those things (such as ROM in restrained limbs), I have just put myself in a very precarious position if something goes wrong with the pt. I agree that it becomes impossible at times to give meds within the window, but to blatantly disregard restraint checks...I cannot justify that.

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