charting times

[Mr. Murse]

Is anyone else's management asking you to chart at precise times, regardless of the time you actually did the task at?

For example, our management has starting asking that we chart shift assessments at precisely 0800 and 1400. Then also chart skin bundles precisely every 2 hours and VAP care, etc, every 2 hours.

The problem I see is that it's obviously not accurate. There's no way I could be assessing all of my patients at the same time.

Would this not call into question the validity of any of your charting were you taken to court? Or is it reasonable to say it was done "within the 8 o'clock hour" or whatever, although not precisely at 8? Is anyone else being asked to do this?

Not that I've ever been necessarily down to the exact minute of charting when I completed the task, but as close as possible.

[RNperdiem, RN]

I have heard of this with restraint charting. They want it charted at exactly 0600, 0800 etc. I go along with it. I know that the restraints get released and assessed Q2 on the even hours because that is when we do patient turns.

The other things seem a little finicky. Maybe it makes auditing the charting easier in these heavily audited times.

[AJJKRN]

We are expected to chart in "real time" as much as humanly possible with making the deadlines either on the minute or before. Maybe it depends on your charting system which really still seems like a lame excuse from TPTB.

[kaylee.]

Most people chart all the am assessments at 8, and the IV assessments at 8, 12, 1600. At first this seemed weird to me too, but not really anymore. If something happens like a run of vtach, i will chart it at the exact time, but other than that, no one has ever said anything about rounding off time of routine assessments.

You bring up a good point though: how does this look in a court of law. Is it problematic. Id like to hear what others think...

[VANurse2010]

I'm ok with that kind of charting for hourly rounds, turns, minor assessments (IV patency etc.), VAP bundle etc. but I won't fudge my times for my actual physical assessment.

[Mr. Murse]

You bring up a good point though: how does this look in a court of law. Is it problematic. Id like to hear what others think...

That's the thing though......ultimately, charting is all about covering our own butts. If you get taken to court by a good attorney, they will eat you up on every little discrepancy they find. If I were prosecuting, I would obviously question the validity of a nurse's charting if they repetitively and obviously mischarted times. It seems like it would be better to guess at the time you actually did something than to say "yeah, I turned two patients, checked their restraints, and cleaned their mouth all at the same time of 8am".

I really don't know though. Just doesn't seem to make sense except for the auditors (as another poster mentioned).

[Mr.F, RN]

We were taught the same thing. My unit wanted assessments at 0800, 1200, and 1600. It was explained to me that if you chart past those times say 0825 instead of 0800) and the patient has an acute change at 0825, a lawyer might point to the fact that you didn't assess your patient within the required 4 hours and thus led to the patient's problems. Also, when you are taken to court, I am not sure if they will have other patient charts to compare your charting times as this may be a violation of HIPAA (unless they subpoena other charts to prove nurse incompetency?). I would be interested to hear from someone in legal about this because I have always questioned it as well! 

[Rose_Queen, BSN, MSN, RN]

Mr.F said:

We were taught the same thing. My unit wanted assessments at 0800, 1200, and 1600. It was explained to me that if you chart past those times say 0825 instead of 0800) and the patient has an acute change at 0825, a lawyer might point to the fact that you didn't assess your patient within the required 4 hours and thus led to the patient's problems. Also, when you are taken to court, I am not sure if they will have other patient charts to compare your charting times as this may be a violation of HIPAA (unless they subpoena other charts to prove nurse incompetency?). I would be interested to hear from someone in legal about this because I have always questioned it as well! 

This is why policies that are too prescriptive are the enemy. My organization recently edited the policies to be less restrictive with exact times so that we wouldn't get dinged for not being exact. for example,

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Pain levels will be reassessed as close to 60 minutes after oral pain medication administration as feasible.