Does anyone else find themselves taciturnly encouraged by their organization to chart lies, or to put it another way, to enter fictitious information into flowsheets? Of course the organization would never want you to come out and say you are doing this, nor would they or you want to think of your little data entries in the flowsheets as not being truthful. We always seem to find ways to rationalize what we are doing.
For example, my facility requires patients in restraints to have q2hour visual checks and in the column for that visual check, you are supposed to inspect skin under the restraint, offer fluids or food, check for incontinence, and perform passive range of motion. You're supposed to check off that you did all this, every 2 hours. Now, I know damn well that neither myself nor my peers actually perform passive range of motion exercises on our restrained patients every 2 hours. Most of these patients you want to avoid disturbing at all costs or they'll start screaming their heads off or try to climb OOB. But we all check off that we did passive ROM. Some people might rationalize this by saying "well, when we change his gown we are performing passive ROM on his arms," or some other equivalent stretch of the imagination.
Another example is charting "patient was turned q2h" when they were turned maybe twice in the shift. Another big one is entering in a CIWA assessment for a sleeping patient. I'm sure there are lot of excellent nurses out there who wake their patients to perform CIWA (which is what you are supposed to do) but most I know will not wake up an alcohol withdrawing patient in the rare moments they can be found sleeping unless absolutely necessary. Yet, they all put in the CIWA assessments on time. I could go on and on, with people charting that saline locks are patent without flushing them, non existent pain reassessments, and so forth.
Do you encounter this often? And being as honest as possible, have you or do you do it? Do you feel that you have much of a choice?
Absolutely not. We are required to do the things we chart on. I can only imagine if I had a patient in restraints and did not check their skin every 2 hours, and they developed some horrific pressure ulcer and I had to explain to someone how they got that between my last assessment and shift change.
Occasionally I write "Not assessed" or "not performed" and give a reason why not (but never on restraints), and sometimes I will not turn a patient per family request but I do put a note in there that the family requested that patient not be turned Q2H but only Q4H per home schedule or something like that.
Specializes in Nurse Leader specializing in Labor & Delivery.
Yes I chart lies sometimes. Our flow sheet has a box for si and hi. If a pt is easily agitated by staff and rather be left alone I am not going to agitate them by asking them if they are having suicidal thoughts . No si it is !
You don't have to say "Are you having suicidal thoughts?"
You can say "Have you had any recent thoughts about harming yourself or anyone else?"
But if you are dealing with a patient who has a psych history, or depression, or ANYTHING mental health related, it's IMPERATIVE that you ask the question, even if it's uncomfortable.
I work PICU and stepdown. In PICU we are required to assess the patient head to two every 2H and most nurses that I know really do the full head to toe as required. Sometimes we have to assess neuro status or pulses every hour and RN's do that. Imagine if a patient had brain swelling or something and the RN did not bother to assess the patient every hour and something horrible happened. Yes I have had to wake up two ICU patients who were having blood sugar issues every hour to take glucose levels and open their eyes and answer some questions. It was a pain but not only is their life on the line but my job/license is on the line. If I can't get in one room to do an assessment on a patient because my other patients suddenly needs a lot of attention, I will ask a co-worker to assess the patient for me and chart it. We do that all the time on my unit. It's good teamwork that keeps the patients safe.
If I have a pt is restraints, they are on a 1:1. I work in acute mental health and we use 4 points not those nice soft padded ones. I also make sure to perform ROM q hr. As far as my CIWA pts go, I never wake up my sleeping pts to do a CIWA. They need to sleep. If it was me, I would be trying to sleep through the worst of it. I don't chart lies. If anything, there are times that I do a lot and forget to chart those things. I'm a work in progress....
Yes I chart lies sometimes. Our flow sheet has a box for si and hi. If a pt is easily agitated by staff and rather be left alone I am not going to agitate them by asking them if they are having suicidal thoughts . No si it is !
Asking the tough questions to both male and female patients is part of being an RN. I've had patients who seemed OK on the outside and then when I asked these questions said they were suicidal or that they were being abused, for example. You don't want to miss something this big.
This is off topic but I can't believe its not normal to have a policy stating you don't have to wake CIWA patients. Ours actually says to DO NOT wake them. Not even for meds unless they are truly time sensitive.
Also, I find it crazy that people don't actually do q2 turns. Maybe its because I'm on a Geri floor but we take turns very seriously!
When I worked in home hospice, one of my coworkers did a home visit and the pt. was asleep throughout the entire visit. Pt. lived alone and had left the door open so the nurse could let herself in. The nurse was honest and charted in the paperwork that the pt. was asleep. However, some of the things she charted could not be ascertained on a sleeping pt. The pt's daughter was MAD. Never wanted said nurse to see her mom again. Got a verbal reprimand from management.
It's quite common for post-surgical patients to wake up in horrible pain because they had been sleeping and weren't given their pain medication. When I worked L&D, I would still wake post C/S patients when pain meds were due and encourage them to take them.
That's what IV pain meds are for. :)
I round my times for routine stuff. Unless I'm trying to capture a rapid change in condition, the exact time just isn't important. It's like back when we had checkboxes under the hour on a giant written flowsheet. My IVs are checked q hour.
I regularly give IV meds without waking the patient. BUT, I always tell them during 10pm med pass, "___ and ____ are due at 0000 and 0200. I'll try not to wake you unnecessarily if you'd rather me not, but I can't guarantee it." Of course I'm on a medical floor with q8 vitals (unless on tele) and one assessment per shift so its easier for us to let people sleep.
Also saw someone say the only thing they lie on is times. This is me. Many nights I'm too busy between 1930 and 2300 to chart anything, so when I come back and finally do my times are often not exact. I make notes on my assessments and stuff so they will be accurate when i do chart them. And I always chart meds exactly when I give them but IV placements, dressing changes, turns, the times get estimated on those.
I saw someone say their charting doesn't have the option of changing the time. I don't like that at all. Some nights I've turned my patient at 1900 2100 2300 0100 and just now have the time to chart it. If I couldn't change the time it would like like I've only turned them once and the night is halfway over!
When I started at my facility, the rule was whoever saw something happen filled out the incident report. A few years back, supervisors were instructing nurses to fill out incident reports on falls even when they didn't see the pt. fall or find the pt on the floor. The nurse assigned to the pt. had to do the paperwork. One morning, two PCTs claimed this pt. fell but their stories didn't match up. When I asked the pt. what happened, he denied falling but changed his story at least 3 times within 5 minutes. The supervisor told me to document what the PCTs said. I reminded her this would be documenting hearsay in legal documentation but she stood firm. I then told her I would add that I didn't witness the pt. falling so was documenting what was told to me by the pt & the PCTs under HER instruction (and used her name). Fortunately, nothing ever came of it. BTW, one night shortly after we went to electronic charting, I was having all kinds of problems with the computer. This same supervisor offered to log in then let me pass meds under her login. My reply? "Um, no, that's illegal."
Now the policy is that if a PCT witnessed the fall (or whatever), they fill out the incident report with help from the shift supervisor. Ironically, we have fewer falls these days.
We have been told that you don't need to wake a patient up, you can write on asleep, obviously can visually see sweating etc, but if they are asleep unlikely to need any meds at that time. Obviously still need to monitor vitals to check not over sedated
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anon456, BSN, RN
3 Articles; 1,144 Posts
Absolutely not. We are required to do the things we chart on. I can only imagine if I had a patient in restraints and did not check their skin every 2 hours, and they developed some horrific pressure ulcer and I had to explain to someone how they got that between my last assessment and shift change.
Occasionally I write "Not assessed" or "not performed" and give a reason why not (but never on restraints), and sometimes I will not turn a patient per family request but I do put a note in there that the family requested that patient not be turned Q2H but only Q4H per home schedule or something like that.