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?
I've seen it all the time. Every time a nurse falsified her time sheet to be paid for work not performed, I have not been the only person aware of the act. Clients encourage it, some demand it, employers usually brush off the report and do nothing. I've been called in, sat down, and told what to do because someone was in the building inspecting or something, and lucky for me, what I was asked to chart was factual. I already knew what kind of employer this was. Down the road I ended up leaving because I witnessed something and reported it. I made a third report outside of the employer because I knew I had to; to defend myself if the employer turned the tables on me, and because I am a mandated reporter. Nobody likes to pay the price for doing what they are legally required to do. Always easier to chart the truth than to be wondering what will be the consequences if one gets caught on the other side of the coin. (Emphasis added.)
Thank you for your integrity. Of course you are correct in what you say. Why do any of us waste even a second struggling with these questions? Because we don't want to pay the price, forgetting that there is a price for not doing what we are required to do... and it's the higher one.
Many of these charting requirements are the result of regulatory bodies and their demands. These are one-size fits all flow sheets that read like nursing school care plans. To me, they should be approached as guidelines.
In the ED, our restraint sheet is q 15 minutes for some scenarios. I just check the boxes. My manager doesn't want us dinged during chart audits. Yes, we all want the pt safe and I am checking on the pt. I never check on the ROM box because I never do that.
I think the hospitals are just as frustrated and we are with unrealistic regulatory demands.
In the real world we try to match up what is individualized to the patient with the demand for perfect charting.
My restraints really are released Q2 hours, how else could I turn patients? The charting is required to say 0800 1000 1200 etc. In reality the times were 0756 1010 and 1155. Try to chart that and see how quickly a chart auditor will get on your case about your charting times.
Charting isn't really much about patient care anymore ,a lot of it is now accreditation and reimbursement.
If someone is having DTs, they aren't going to be on CIWA. They are going to be in the ICU on MINDS. DTs are lethal and involve seizures and cardiac instability.
Tons of people undergo DTs because they were undermedicated on the CIWA protocol, often due to nurses deferring assessments because they don't want to wake up patients or giving artificially low scores to sleeping patients. That is what is dangerous.
I've seen it happen on a tele floor. Pt was An ETOH w/d admission, had a seizure, rapid response was called, and when the nurse was asked the last CIWA, she said, "He's been sleeping all morning!"
In the real world we try to match up what is individualized to the patient with the demand for perfect charting.
My restraints really are released Q2 hours, how else could I turn patients? The charting is required to say 0800 1000 1200 etc. In reality the times were 0756 1010 and 1155. Try to chart that and see how quickly a chart auditor will get on your case about your charting times.
Charting isn't really much about patient care anymore ,a lot of it is now accreditation and reimbursement.
I posted elsewhere that a CNA had the perfect timing for turns that she didn't do, but I was told I was wrong for charting in real time the turns that I did do, which had times similar to your real ones.
Wow. Sounds like you work at a terrible facility. Restraints should almost never be used, and if someone is put in restraints, they undoubtedly SHOULD have extremities (one at a time) freed w/ active OR passive ROM q 1-2 hrs. Shame if you are not doing this!!!!
Hearing the pain in the butt CIWA is I'm very happy that I'm in the ER! We just go by clinical judgement and they either tolerate the meds or get intubated for higher sedation. The floor nurses have to put up with so much crap I know I couldn't!
When it comes to documentation of restraints the timing depends on the type of restraint. If it's medical restraint, like with an intubated pt, we chart q 2 hours. If it's behavioral, because they're attacking, it's q 15 mins. Just depends.
In my practice I try my hardest to chart only what was done or what I saw. Sometimes it's hard being objective, but I keep trying to improve every day.
Specializes in Acute Care - Adult, Med Surg, Neuro.
I always chart the times I did things. Sometimes that means if I only am able to turn the patient twice during the shift (8 hours) due to being busy, then that's all that gets charted.
I don't have much experience with restraints (we rarely use them) but I have a lot of experience with CIWA. We do not wake our patients up to do the CIWA score. I have never had a patient go into DTs, however I have over-medicated a CIWA patient enough to require reversal agents. I tend to be very liberal with medicating because the patients are so miserable during the acute withdrawal period, and I know how dangerous DTs are. But I think if they are very sedated from the meds, it's not a good idea to give them more.
[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?
Actually I work at a facility that does medical detoxes and we DO NOT wake them to perform CIWA. Sleep is essential for these pt to recover. They often dont sleep for days which can add to the delirium. I have linked an article from Vanderbilt University that actually states in their protocol to NOT WAKE a patient , but hold meds and assess when awake. Have you ever had somebody climbing furniture thats been plowed with 20mg of ativan + haldol FINALLY get to a point to sleep. Why would you wake them in an hour to give more medication?
Also sometimes no matter how many medications you give the pt will still go into DT's I have had pt who received 22mg of ativan in less than 24hr as well as 15 of haldol and still went into severe DT's. My unit isnt monitored either so that can be scary.
Just thought I would share, some units protocol is to actually let them sleep. I have had many pt IMPROVE once they get a few hours of uninterrupted sleep. I still assess breathing,sweats, even vitals but I dont wake them to ask if they are seeing things. If they are sleeping then they are probably not actively hallucinating
SeattleJess
843 Posts
Thank you for your integrity. Of course you are correct in what you say. Why do any of us waste even a second struggling with these questions? Because we don't want to pay the price, forgetting that there is a price for not doing what we are required to do... and it's the higher one.