fabricating data on care plans and patient assessment writeups?!

[mother_baby_RN]

I'm an accelerated BSN student about 70% of the way through my program. Right now we just started a really tough quarter where we have 2 intense classes and clinicals (OB & Peds - OB is my absolute favorite). Many written assignments are required for the clinical portion of each course, such as detailed patient assessments and care plans.

Today I was just lamenting to some friends about how some data required to be included on the assessment is near impossible to find in the patient chart, far too random (and possibly inappropriate) to discuss at the bedside, and, most importantly, not at all relevant to providing care for that patient. We are penalized if we have any "data gaps" on our care plans and patient writeups, the idea being that we should gather all "necessary" information during the clinical day. For example, one template asks us to get the age AND date of birth of the patient's partner.

I mentioned to my friends that it seemed silly to have to do age and DOB. They laughed and said make it up, of course! They said they've been making stuff up all along for these writeups. These are purely academic exercises - they don't get added to charts or used in actual patient care. But they'll even throw in typical normal values for labwork they can't seem to find but they know was in normal range.

Personally, I feel this is a gross violation of what nursing is about. Our program values ethical behavior above all else, and we were told at the very beginning to never falsify or fabricate any patient data.

Has anyone else seen this happen in their school or among their students? how did you address it? I am feeling resentful that I'm doing things by the book while others may have many fabricated details making their care plans appear to be much more thorough.

[Despareux]

Please don't lose your sense of integrity for the sake of convenience. Hopefully your friends were joking. I would just worry about what you are learning; not how or what everyone else is learning. And most importantly, CYA.

[Mandychelle79, ASN, RN]

personally I would write information not available. Shows you did look for it but it was not there.