Do you chart lies?

I don't believe a single nurse, save possibly ICU, who tells me she doesn't copy/paste at least some of the assessment info from those flowsheets. Regulatory bodies are not nurses. In a perfect world....

I neither have the ability or the stupidity to do so. As I asked earlier..Have you ever sat in a deposition?? I have, and it's not fun and I wasn't even in the hot seat.

Thanks for the kind words. No one wants to admit to themselves that they're responsible for cutting corners like this. In earnest, I believe that the people in this thread who admit to having charted lies are actually more honest, trustworthy people than the ones saying they never have. Ironic but true.

Nope, 30 years in the health field and never...ever have. What is the reason for lying??

I feel for you RN dynamic. Wait until you get called to testify or sit in a deposition. Will you remember your lies? Probably not. How can you go back and defend what you did, when you can't even remember the lies that you charted?

Nope, 30 years in the health field and never...ever have. What is the reason for lying??

I feel for you RN dynamic. Wait until you get called to testify or sit in a deposition. Will you remember your lies? Probably not. How can you go back and defend what you did, when you can't even remember the lies that you charted?

Wish I could like this more.

If anything, I have been a chart reviewer in my career for CMS; even though a reviewer is supposed to "capture" specific criteria in order to reimburse; looking at those charts made me even more vigilant in terms of accurate charting.

So, no, I'm not holier than thou when it comes to charting; I chart in real time; and I have yet to be pulled in or written up for inaccurate charting; and I chart what I do, and to the point of what needs to be charted.

Now, if a facility decides to tamper with my documentation; thank goodness for malpractice insurance.

Well.. no judgement here, but there is no way I would sign off on something that I didn't do, or didn't see. That is just me. I would rather the record reflect that we missed an interval, or an item rather than falsify a document that could end up in court!

If it isn't documented, it wasn't done...I am so disenchanted with this.

If I make protecting my license my priority, I HAVE to make time to document.

That time often comes at the expense of patient education and compromising the patient experience.

Ever since my first clinical rotation when my eyes were open to the difference between what we are taught and the "real world," I just can't understand why nurses are not set up for success, but must always weigh priorities, patient safety and ethical judgment to do the best they can.

I felt this same way my first time in c linicals. My instuctor had me clicking things I hadn't done but now if I miss something I go back in and check abd get the answer or levee it blank. It's important to me t o chart the truth

What type of retraints is the patient in that require checks q15mins? How would you get anything done? I thought the standard protocol was q2hrs. I guess it depends on the facility.

What type of retraints is the patient in that require checks q15mins? How would you get anything done? I thought the standard protocol was q2hrs. I guess it depends on the facility.

In our facility q15 min restraint checks are when restraints are use for behavioral or violent patients. Otherwise q2 hour for medical reasons. In 5years, I have only seen the behavioral restraints used once, and it got switched to the medical type pretty quickly for obvious reasons.

I work in LTC at a SNF and we have 30 patients per nurse. Of these 30 patients we are to sign off that we do a full head to toe body audit (skin sweep) on approximately 10 of these patients per shift. Now lets be serious... How in the hell would it be possible to do a FULL body assessment on 10 patients in an 8 hr shift when you are also responsible for passing meds to 30 patients, glucose monitoring for 10 patients, GT care for 5-6 patients and treatments as well as documenting. This is impossible to do yet we do have to chart that we do it or else... I absolutely HATE documenting that I do a full body check on that many patients when I know that I barely get the chance to look at 2 or 3 let alone 10. The DON/DNS simply states "this is where TRUST comes in and you have to be able to rely on your CNA/PCT to let you know if they notice any skin changes. Well I do not feel comfortable placing that on a CNA/PCT because if they fail to report it (which we all know we get some people who just don't care) we are the one in trouble. UGH! The joys of nursing! Nursing is no longer "nursing" it is more politics and paperwork than actual hands on care.

Erika

Violent restraints. Non violent is q2hrs.

So many times management has said "you know we get dinged if you dont chart that." I reply, "well I could lose everything for lying in my documentation. I refuse to lie." That shuts them up

About self extubations: it's been shown in the literature that unrestrained patients do not have significantly higher rates of self extubations than restrained patients who use all sorts of creative maneuvers to get the tube out. They will shake their heads. Use their tounges. Sit up and bring their head down to their hands. Or bite the tube clean through. There is no substitute for eyes on the patient. Of course this isn't always achievable, but ICU nurses spend a lot of time in patients rooms, assessing everything about the patient, including restraints. Yes, turning and positioning does happen Q2 hours on my unit. So does releasing restraints and monitoring them per protocol. So these tasks are completed, not always at the exact time such as 8,10,12.

If one has enough time to watch other nurses and see how their tasks match up with their charting, then one has time to do their own work and not have to falsify charting.