False documentation... more common than you think.

Nurses Safety

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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.

I wonder if this is becoming a problem with the high level of scrutiny charting now gets to meet state/policy requirements.

Charts are audited like charts have never been audited. Computer charting makes this easier.

If you have a patient in restraints, your charting must have exactly 2 hours between assessments that you untied the restraint, offered care etc. You will hear very quickly if one assessment was at 0800 and the next one was at 1010.

But what if my Q2 hr turns, checks, assessments happened at 1010 instead of exactly 1000?

Specializes in LTC and School Health.
Just because some nurses assert that they do not falsely document does NOT in any way imply that they are saying they are "perfect" and it is unfair and misleading to suggest that they do.

Didn't mean to apply that and that is not what I meant. I'm speaking of holier than thou nurses, that berate other nurses for making mistakes ( not falsifying records) or admitting imperfections.

AN is great for support and advice. Most posters are very kind, but then there are some that are down right nasty. Just saying.

As I stated in my OP, I admire nurses who didn't have to do "creative documentation" unfortunately, I worked in LTC with 60 residents I had to chart on. I could not be 100 percent that each one was turned and toileted q2h, guess I should turn in my lic. and be stoned.

Specializes in LTC and School Health.
Thank you! I am certainly not perfect, but I also do not willingly commit fraud.

I'm not perfect, no nurse it. I don't willingly admit fraud either.... or atleast I hope that is not how my OP seemed. Maybe you should go back and re-read it.

Specializes in FNP, ONP.
Meh, I do it. Never making up vitals, but hey- I have 30 people to chart on.

I KNOW Ms So-and-so's sugar is going to be sky high after she just ravaged that cake, I'll jot down- "BS elevated, covered per sliding scale. Appetite good." However, my lot of 30 only changes every so often, so I've become familiar with them. It's not a "Lie", it's an accurate prediction based on her history, and current activity. ;)

If I were on your BON, I'd pull your license for this.

OK, I redact that after reading your clarification, lol.

There are so many professional adults yelling at others in this thread. Or calling someone on something another said. It sounds like attacking.

I feel like the profession we work in is hard enough, physically and emotionally. Then we spend time on the internet getting upset and arguing at one-another. It just makes me sad; this place is a support system. A place to lift your spirits, get help or advice, or information. Not to yell at someone because you don't agree with what they said. If you disagree, please disagree nicely.

*Off soapbox, back to the comics section*

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.

Staffing is very inappropriate in more than one field in 2012. Whoever is responsible ultimately has to be at or above the level where schedules are made, hiring is done, ratios are decided upon, etc. They call those levels "management".

Like when people criticize whether or not the US should/should have military missions in Afghanistan, Syria, etc. Soldiers don't make those decisions. Brass do.

Rather simple concept, I thought.

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?

Specializes in Gerontology, Med surg, Home Health.

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.

Specializes in Foot care.

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?

Specializes in Foot care.

Really, is this common practice? I'd like to know.

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.

I too have complained right up the ladder,but then you become the problem....it is your skills etc. I find going outside the facility ....not willing to get involved. there is a lot of redirecting back down. I think going to the media collectively would be best, but people are afraid.

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