Charting, done by the amazing psychic nurse

[DesiDani]

The gifted nurse who charts what he/she never did, seen, or acquired about.

Does it ever catch up to them?

[iluvivt, BSN, RN]

You are violating the Nurse Practice Act if you make up vital signs and assessments and then charting them as fact! I can't and will not ever do that because I would never want that done to me or someone I love. There is a difference with following up on pain assessment scores after administering a prn because you can always just ask the patient or tell them ahead of time they need to make a mental note of their pain score at the specified time. It is a lie and falsification of records to chart you tuned the patient when you did not or see to it that it was done. I personally could not live with myself if I had to lie like that and then justified by saying it is your employees fault. You are either a professional or you are not!

[beckysue920]

I don't care for falsified records...I learned my lesson early in my career when I reported for my 7 AM day shift and did early rounds on all the psych patients on the unit. I found Mr. D dead as a door nail with rigor. His night nurse had charted: Asleep, Asleep, Asleep for all checks. I guess Mr. D was asleep...forever. I secretly thank that nurse for reaffirming my ethics.

[neuron]

No. As long as the boxes are checked no one cares.

If the family complains about serious negligence it might be addressed. They also have the option to file a complaint at cms.gov

Don't make it easy for her to falsify charting by giving her your assessments.

The least that a nurse can do is give the meds and I have met two in my career who didn't even do

that. Patients complained management knew and chose not to do anything about it. The nurse who reports gross negligence is labeled a problem.

And shady employers actually prefer shady nurses.

So unfortunate.

[Platypus]

I work night shift and we are required to chart on certain rooms/patients (rotated between shifts) so there is at least one note a day on the patient. They don't want "patient slept all night". They want to know how the patient ambulates, treatments they get, if they are doing OT, PT, ST, are they continent, incontinent etc. Sometimes, I may never see a patient ambulate, go to therapy, how they are eating/drinking ... but I still have to chart on it. I rely heavily on report, previous notes, doctors notes and my CNAs who actually spend more time with certain patients than I do. I don't like it, but Admin is happy and state is happy.

[kbrn2002, ADN, RN]

I work night shift and we are required to chart on certain rooms/patients (rotated between shifts) so there is at least one note a day on the patient. They don't want "patient slept all night". They want to know how the patient ambulates, treatments they get, if they are doing OT, PT, ST, are they continent, incontinent etc. Sometimes, I may never see a patient ambulate, go to therapy, how they are eating/drinking ... but I still have to chart on it. I rely heavily on report, previous notes, doctors notes and my CNAs who actually spend more time with certain patients than I do. I don't like it, but Admin is happy and state is happy.

We used to do this until the night staff [mostly me] rebelled. It made no sense to me to chart to things that I don't have a clue about. I have no idea if that resident is actually participating in therapy as ordered. I don't know what activities they participated in or how their ADL's were performed that day. I can look up bowel and bladder details and how much they ate but that still isn't the same as being able to actually witness their level of functioning that day. This charting requirement was moved to an AM/PM rotation as my arguments against NOCS being responsible for this made sense to the DON. This is for required detailed weekly charting by the way. Our daily charting residents require much less detail and NOC shift functioning is charted to what we do, not what another shift may have done so if they actually sleep all night that is what we chart.

[%D#2]

If people are having confusion on how to chart I would do as a PP said and get more info from CNAs and other info. Also the patient, if able to communicate, often provides the most insight. Go straight to the source. I don't believe in falsified charting because this all goes back to why we chart in the first place. It's not just for management or covering our butts. It's very important that when a doc comes in, they can look at chatting and see ACCURATE info on their patient. That's a crucial part of assessment is it not?

[SmilingBluEyes]

nevermind.