False documentation... more common than you think.

[OnlybyHisgraceRN]

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 threads have been helpful many members feel the need to judge the OP for false documentation.

In my opinion, many floor nurses are guilty of false documentation, so what gives some of you the audacity to judge and berate another nurse.

How many times have you given a medication outside of that "one hour" window but charted it was given on time?

How many times have you documented your assessment at the time it was supposed to be done, when in reality it was done much later or even much earlier.

For my LTC, nurses are you 100 percent positive that your 20-60 residents were turned and repositioned every 2 hours, or that each one of them was toileted every two hours? Yet you will still initial those two initials in that square box.

When I was a nursing student I would often floor nurses "magically" come up with a patients weight, vital sign, or blood sugar and document, knowing that it was NEVER done. I was so quick to judge as a student and thought their license should be taken right away. After working as a nurse, I realized that while I don't condone that behavior I understand it.

If you answered NEVER to all my questions you are either a super nurse or either you work in a place that have perfect staffing, perfect patients, and perfect coworkers.

The purpose of this thread was for us to sit here and evaluate ourselves before we judge someone for false documentation.

I'm not talking about the nurse that is clearly negligent, lazy, and etc. I'm talking about the nurse like myself who provides competent and quality care to patients but faced with staffing issues that makes it nearly impossible to document every single thing as it is being done.

Unfortunately, some of us work in places where we no longer take care of patients but instead we are taking care of the higher ups in their effort to please the state.

Maybe if we can get rid of some of this customer service BS we can actually have more time for proper and precise documentation.

We are saving lives everyday. I rather give a calcium chew tablet 2 hours late than to ignore my patient that has CHF and having SOB.

So the moral of this story is that people in glass houses shouldn't throw stones.

For all of you nurses that never had to participate in "false documentation" I admire you, envy you and hope to be like you when I grow up.

[wooh, BSN, RN]

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.

[Horseshoe, BSN, RN]

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.

[mindlor]

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.....

[psu_213, BSN, RN]

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.

[psu_213, BSN, RN]

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.

You do not need to note that this is a late entry. Yes, it's best to chart right after doing the assessment, but sometimes that is not possible. Now, I am not sure if this is a policy at my facility or if it is the law, but it is my understanding we have up to 24 hrs to chart something before it is considered a late entry.

[Horseshoe, BSN, RN]

You do not need to note that this is a late entry. Yes, it's best to chart right after doing the assessment, but sometimes that is not possible. Now, I am not sure if this is a policy at my facility or if it is the law, but it is my understanding we have up to 24 hrs to chart something before it is considered a late entry.

^^^^^That takes quite a lot of pressure off of the nurse.

Back in the old days when most of our documentation was pen to paper, if you had forgotten to chart something you had done earlier in the day, you had no choice but to add it at a later time and note that it was a late entry. With computer charting, it's easier to make sure you "get credit" for doing your work even if you can't chart it as it happens.

[kalevra, BSN, RN]

Keep in mind I am an RN student.

Thank you OP for posting this!! I have seen RNs I worked for apply "creative" charting on the floor I have been on and in different hospitals. Specifically hourly checks like bathroom or being turned. I also understand as to why they do it though. I mean you get behind or something comes up and usually something does come up. Sad to say, but yeah its the nature of the job.

The part that I laugh about is the hypocrisy in the system. RNs that claim they have never used "creative charting" in their 15+ year career are the funniest. I worked for a few of them and I swear I saw them write down their assessments an hour late because something came up. They are quick to berate another RN when they see it go down, but when its them doing it well you know they are an exception to the rule.

I can also understand the motivation for not making a big stink about reporting people for "creative charting". The "the nail that sticks up will be hammered down." I saw nurses report doctors to higher up for hitting the scrub tech while in surgery, and no joke the nurse was put on "administrative leave" the following day. The doctor was still on duty since I had to be in the OR again the same day. Yeah and after a few articles of nurses being "let go" after they reported some unsafe practices/complaints it is easy to see why keeping you head down is the easier choice. Its not the righteous choice but you get to keep you job and feed your family. Not having a target painted on your back by higher up may be a wise decision in this economy.

[Horseshoe, BSN, RN]

Keep in mind I am an RN student.

The part that I laugh about is the hypocrisy in the system. RNs that claim they have never used "creative charting" in their 15+ year career are the funniest. I worked for a few of them and I swear I saw them write down their assessments an hour late because something came up. They are quick to berate another RN when they see it go down, but when its them doing it well you know they are an exception to the rule.

There is no ethical rule that a nurse must chart her assessment the moment she is through. What you have described is not "creative charting." False documentation would be charting an assessment when none was ever done.

[Teacher Sue]

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.....

No, it is not a personal affront, it is an observation. In several threads, you have stated that different issues are due to management's refusal to staff appropriately. This leads me to think that you believe all managers and administrators are greedy and evil. Yes there are some power hungry selfish administrators, but this is true in any profession. Most managers and administrators do care about patients and staff. But we are forced to function within constraints applied by state and federal governments and regulatory agencies that require more documentation and that we meet stricter standards of care. With ever decreasing reimbursement and higher acuity patients, it is becoming more difficult to provide good care and remain fiscally responsible. It is very frustrating to see staff struggling to meet patients' needs. This is why I spend most of my mornings on the unit helping with care, then stay until six o'clock every night to complete my administrative duties.

[kakamegamama]

No. Just note "late entry" or "late entry due to....."

[BonnieSc]

Keep in mind I am an RN student.

Thank you OP for posting this!! I have seen RNs I worked for apply "creative" charting on the floor I have been on and in different hospitals. Specifically hourly checks like bathroom or being turned. I also understand as to why they do it though. I mean you get behind or something comes up and usually something does come up. Sad to say, but yeah its the nature of the job.

The part that I laugh about is the hypocrisy in the system. RNs that claim they have never used "creative charting" in their 15+ year career are the funniest. I worked for a few of them and I swear I saw them write down their assessments an hour late because something came up. They are quick to berate another RN when they see it go down, but when its them doing it well you know they are an exception to the rule.

Kalevra, it makes me sad to see this attitude in a student. I think part of the problem is the wrong attitude (reinforced by some of the nurses you have trained with) and part of it is a misunderstanding of the terms being used here.

I suggest you drop the idea of "creative charting" from your vocabulary. Where it was originally employed here, it meant LYING. I'm all for actual creativity, but I can't think that it is ever appropriate in charting, except perhaps writing skills used to get across a difficult concept or describe a particular patient. (Though in one hospital I worked for, there was no narrative charting at all--which I generally prefer.) I can't imagine that "creative charting" is a term used for anything you want to emulate.

I very rarely chart my assessments within one hour of doing them. I know some nurses who do--they have the assessment open on the computer in the room and chart it as they're doing it, or immediately afterward, before they leave the room--but this has so far proved difficult for me; I like to focus on charting my assessment, and my attention is pulled in too many different directions if I'm at the bedside. And I don't have time chart each assessment at the nurse's station between patients. Too much is going on in the first two or three hours of the shift. I do COMPLETE my assessments within two hours of the shift--almost always. Sometimes there are codes and other situations. In those cases, another nurse checks in on my patients to make sure everyone is breathing and cared for. And if I do my full assessment three hours into the shift, I chart that I did it then. Anyone who looks into my charting can see exactly when I charted it and when I say I did it. I'm not hiding anything, and I'm not trying to hide anything. (No need to make a "late entry" statement, at least at my hospital, unless I want to make it clear that I'm charting with hindsight--for instance, after a code. I had a patient code while in restraints once, and I tried to make my charting impeccable so that it was clear I wasn't trying to cover anything up when some of the events were charted after the fact.)

Is there hypocrisy in nursing? Yes, you are absolutely right. It is SO much easier to catch others' mistakes, and criticize others' methods, and look down on others' lack of knowledge, than it is with yourself!

But the last thing I want to say is that false documentation is NOT "the nature of the job". Don't think that because you see nurses doing this, or read about it here, that it is acceptable practice. Ask your teachers what they think. I will readily admit that there are some practices in nursing school that are a little pie-in-the-sky when it comes to actual practice, but this isn't one of them.

[OhioCCRN, MSN, NP]

I would be willing to bet a million dollars of money that i don't have, that EVERY SINGLE ONE on this thread has creatively charted... so just STOP with the hypocrisy!