Documentatio question

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Specializes in M/S/Tele, Home Health, Gen ICU.

Is it ever OK to document on a patient chart ahead of time, eg make an entry for 10 00 at 07 00. Thanks

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Specializes in HEMS 6 years.

Only if you are omniscient.

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Specializes in Education, FP, LNC, Forensics, ED, OB.

hello, celia,

no, it is never o.k. to document anything before the fact. why would you? and, why do you ask??

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Specializes in M/S/Tele, Home Health, Gen ICU.

Siri, I wouldn't but I have seen it done. Celia

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Specializes in Education, FP, LNC, Forensics, ED, OB.

I had a feeling this was on a personal level. If you work with those that do this, you need to report it. This is wrong on many levels. And, if something were to happen to the patient before the documented time of what was (wasn't) done.... well, I think you can draw your own conclusion/s.

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Is it ever OK to document on a patient chart ahead of time, eg make an entry for 10 00 at 07 00. Thanks

DUH!!!!! NAW!!!!! What if you have to document something else that happens at 8:00 and you've already writen 10 down? No way to cover that up is there? Chart when you do it. Or I take notes all night in my notebook with times on what all i did and then when i get done with my first med pass i go chart using my notes with the correct times on them.

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Specializes in Emergency, Trauma.

Or worst case scenerio, say you chart meds, or god forbid, an assessment for 1000 at 0700, and your pt codes and dies at 0800? what if he leaves AMA? What if the pt is away at a test or procedure at the "charted time?" STUPID practice that should never be done.

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It's never okay - no way, no how. If it's been done, that person could be in for big trouble if found out. No one is psychic (sorry, not a believer in that) - and it could come back to haunt you.

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Specializes in LDRP.

OK, does anyone really believe that this is okay? Come on, I sure hope not.

What in the world could you possibly be so sure about that you'd chart on it 3 hours ahead of time? 3 hours is a long time.....

If you are caught fudging stuff like that, you will likely be seen as fudging other things as well. Makes ppl lose trust in you.

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EastTxLVN: You say you take notes all noc long then rewrite them. I don't say this is wrong, or illegal, but I have a word of caution for you. One "sign" of medical record tampering can be how "neat" a record looks. Let me explain. If you were to sit down at the end of shift and could write your notes without interruption they would look neater and more consistent than if you wrote them throughout the noc, some "on the fly" because you were in a hurry. Do you follow me? If that record were pulled someone would most likely ask how you had been able to write each individual entry almost consistently. Just a comment on my part. MLF/RN nurse

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Hope you have good liability coverage. Your looking for a lawsuit. As the other messages have stated, don't ever chart before you do it.It's bad nursing practice. Do the chore then document, even if it's later on in the shift. You'll be able to sleep at night or day depending on the shift.

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Specializes in Critical Care.

It's like meds in my opinion. 30 minutes before or after. I MIGHT document a 1000 bp at 0930, but not before. And I normally try to make sure it's documented by 1030 (because docs need up to date info, and because charting is best done if you stay on top of it - that is the biggest issue that makes you have to stay late to finish up.) And I don't like staying late. Also, if you document after the fact after lots of stuff has happened, if you get into a code, then your chart just isn't up to date. Makes you look bad, even if you have all the correct info written down somewhere else.

~faith,

Timothy.

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