I work on a "chronic" unit (our patients are here for months or even years). Each nurse is assigned a certain amount of paperwork (pertaining to our patients) that is due each month. I am always current on my paperwork load for the certain patients that are assigned to me.
I have this one patient assigned to me since the spring of this year, 2010. Previously, this patient was on another unit, assigned to another nurse. There was supposed to have been an annual nurses note/assessment done on this patient last year, by the nurse who was assigned the patient at that time. However, that nurse did not do this paperwork then.
My supervisor (who has been our supervisor for less than a year) told me that I have to do it. I told my supervisor I didn't feel comfortable, since this assessment was pertaining to the patient from 2008-2009, and this patient wasn't even on my unit then. I also voiced that it is not fair for me to be doing another nurses notes that were assigned to her/him. Her explanation was, "well I'm not tracking down who was responsible for this at that time, because I don't feel like doing that." Was this action by my supervisor fair?
2. make a note on it that says that you were asked to do the assessment and that the supervisor who assigned this to you knows that the patient was not in your care doing 2008-2009
3. that you are basing your assessment on what you have learned of your patient since you started caring for him/her.
Is there someone higher up that you can "casually" mention this circumstance to in order to make sure you're not doing anything that could get you in trouble? Believe me, she's not gonna save your ass if it turns out you made a big no-no.
By the way, I'm a bit confused. Is she actually asking you to backdate the report OR is she just asking you to fill out the report now (including the current date) because it was never done?
Tell her that if she wants to falsify records, she can do it and have the responsiblity for it, but you will not. If she pushes the issue, take the write up. I would rather have that than explain to the nursing board why I would falsify records, but I bet she won't write you up for doing the right thing. That would leave a written trail of her incompetence.
I am wondering if the DON meant a review of the patients chart, significant health events, etc. for the period of time from 2008 to 2009. That type of review can definitely be done by any nurse with access to the record if, indeed, it is basically a chart review. The review would be dated when actually done but it could clearly indicate the time frame covered. However if a physical assessment is a component of the review then it must be dated when it actually was done.
If it needs to be done, of course you should date it the day you do it. Can you make a note that you were asked to do the yearly assessment for xyx yr on this date by so and so. When you do these type of assessements you they are probabaly asking you questions that you need to review the chart for and should have supporting documentation for in that chart. In LTC, we do assessments quartery and yearly (and more often for medicare and other insurances). Often times that nurse doing it, might not have ever seen the patient, but does the assessement based on what has been documented in the chart. As far as it being late..date it the day you do it.
It was a yearly assessment that was due in Dec. 09. There was another nurse that was supposed to do this yearly assessment at that time back in Dec. 09!!! Now do you understand Clemm???
What I meant was you can do an assessment NOW about how your patient is NOW compared to chart comments from BEFORE. Obviously you can't write something from 2009 and backdate it.
Specializes in multispecialty ICU, SICU including CV.
No, in a word it is not fair. Your supervisor should require the responsible nurse to do her work.
Said nurse may not still work there. I am wondering if this is part of the reason why the formerly responsible nurse wasn't asked to do it. Wish OP would come back and say something.
No. You can't backdate. That's illegal. If you had taken care of them then, then you could make a "late entry" assessment with the current date and the date that the assessment actually took place noted on it, but since you didn't take care of them, you can't. Tell her to do it herself if she's so concerned. Actually, what would be great is if you asked her to give you that command in writing, so you could then show it to whoever is over her so they know she's asking you to commit fraud. But I'm a butt like that.
Specializes in Infusion Nursing, Home Health Infusion.
I would do a summary from the time I assumed the care so if that is say from Febth 10th through July the 15th 2010 ( just an example). That way you are doing what she asked (sort of) and summarizing the care...just not in a time frame that she wanted. I think the supervisor needs to track down the other nurse but you can not of course force her to do so...ALL YOU CAN Do is document a summary from the time you assumed care. You can also just do a summary as a chart review and state that as such. I have reviewed the chart and nursing care provided from this date to this date and is summarized as follows.
I agree with the many who have replied. If you must do this paperwork.... then do it, BUT make sure you document for the time the patient has been in your care. Anything outside of that is falsifying medical documents and your license is not worth someone else's laziness.
morphed
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You should do the assessment but
1. date it the day you do it
2. make a note on it that says that you were asked to do the assessment and that the supervisor who assigned this to you knows that the patient was not in your care doing 2008-2009
3. that you are basing your assessment on what you have learned of your patient since you started caring for him/her.
Is there someone higher up that you can "casually" mention this circumstance to in order to make sure you're not doing anything that could get you in trouble? Believe me, she's not gonna save your ass if it turns out you made a big no-no.
By the way, I'm a bit confused. Is she actually asking you to backdate the report OR is she just asking you to fill out the report now (including the current date) because it was never done?