False Charting

Nurses General Nursing

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From NancyRN in a thread in the politics/activism forum

Finally, NURSES are going to have to stop FAKING their CHARTING!! I can't count the times I've followed a nurse who charted that she was in a room every 2 hours checking vitals when I know she wasn't. Nurses have to start saying "I didn't get to see that patient for 5 hours because I had too much work to do" and stand together on this issue instead of hanging each other out to dry (I don't know why SHE can't get done...I can!).

I saw this some in the hospital I worked at and A LOT at a LTC facility. There's no foolproof way to ensure that a nurse has done everything just as he/she charted (unless you want to add 24/7 videotaping of each pt room, and in this litigeous society, it's not so unimaginable). And honestly, on a busy day, some things might NOT get done. But how much, really, isn't being done and is still being charted? Of course, almost always these are routine activities that the occassional missing of isn't noticeable. But why should nurses uphold the farce that they ARE doing ALL that they are technically supposed to do and chart? Because if they complain, it won't change. They'll just be told that something's wrong with THEM... everyone else can do it, they don't complain, see how they charted that they did everything just so?

This ISN'T the case everywhere. The hospital I was at was busy and stressed nurses to the limits, but not beyond (for most). The LTC asked for more than was physically possible (4 min/pt to pass meds-adm puffers, eye drops, take BPs, pour meds, crush pills, gently help frail confused pts to swallow a handful of pills, mix fiber drinks, chart as given. Of course, pouring meds ahead of time and charting after passing all meds were against policy, but how else could it be anywhere close to possible without certain shortcuts AND give ALL meds WITHIN THE SPECIFIED TIME FRAME? And god forbid you help a pt up to the bathroom (buzz the aide) or need to take a phone call from a family member during that sprint.

Maybe you're not in the kind of situation. Maybe that's why you're still in nursing. Any thoughts? Be honest.

Folks who say "my job is JUST as impossible, no WORSE, and I CAN DO IT, and anyone who can't shouldn't be a nurse!" need not respond. If everyone were such superpeople, we wouldn't need more nurses, the few could do it all!

Specializes in geriatrics.

I also do not advocate false charting but I think that people who do it are afraid of the "if its not charted , its not done" and they worry that they could lose their liscense over that. Kinda creates a double bind, damned either way. I agree that the problem is not enough time to do it all. My manager has pulled me in for my "excessive overtime" and told me to leave things for the oncoming shift. Wish they could do my chrting, but that is never going to happen. Management will only understand money issues and getting out on time by false charting is going to lose nursres their liscenses for falsifying records and it undermines the effect of the money issue because "some nurses are able to get out on time, their must be a problem with YOUR time management skills that you are not able to" that the rest hear because they need to work over to finish. (hope this makes sense, its a subject that truly frustrates me!)

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A m/s nurses worked very short on evening. There was only a registry RN and two aids, and her for 29 patients.

After she left 3 hours after her shift was to end she filled out an incident report stating the to her knowledge no major harm came to a patient. As the resource for the registry she was responsible for all the patients. PRN medications were delayed. Patient care suffered. She also wrote:

"My documentation is incomplete because after eight hours of non stop nursing care I cannot remember all that was done."

Next time she worked the DON came to the floor and took a report so she could meet with the hospital attorney. She told him the truth.

Now when this nurse is working there is excellent staffing.

Unfortunately when she is off the floor is not staffed as well.

I fill out more incident reports now.

PS: If a doctor asks me to fill out an incident report I ask that MD to do it. If I think it appropriate I do one too.

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gwenith - it's from a thread on "importing nurses" on the nursing activism/politics forum on this allnurses.com

sitehttps://allnurses.com/f100

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I do not false chart. However, I do seem to be at work longer than I should have to be because while all my work got done, I now have to document it everywhere, and I mean everywhere. I am well organized (at work anyway) ;) but on those really tough shifts, I come home and think it must have been a bad dream that I just lived through.

I am thankful that my facility is well staffed and there are not too many of these shifts, I don't know how I would do it otherwise.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

LORD how i love charting by exception on flow sheets---cuts down SO MUCH TIME writing and leaves me more time to DO the assessments I SAID I DID.

I don't lie on charts, either. I would just hate to see a chart on the overhead in court, not knowing for sure if I really did something or not....

it would really bug me.:confused:

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

I agree with the assumption that false charting lets management know that you are able to handle your assignment. If you have an unsafe assignment of 10 patients, then chart that you did assessments on 10 patients every two hours what message are we giving? We are giving the message that we can handle ten patients.

What's sad is that when we are called into management, we are offered counseling on our organizational and time management skills.

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Loved flow sheet and charting by exception also. Here a shift assessment is done every 8 hours, if there is something that happens after the assessment it is charted. Otherwise the shift assessment is good for 8 hours. Of course, we have to chart these assessments first, then change them as condition of patient changes. I do not like to accept the assessment of the last nurse to see the patient as gospel. been burned a time of two, so I do my assessments as I see them. It has brought me some trouble at times, like the 4+ edema vs. trace edema, but I stand by my charting. As I stated earlier, I pray every shift for the "nursing angel" to watch over me. I have been offered time management tips too. I always say, "that sounds so good, how about You showing me for the day, maybe I can catch on better that way." Amazingly, they are always too busy to come onto the floor and do as they say, so I just plug along doing the best I can.

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false charting is like faking an orgasim

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barefootlady said

I always say, "that sounds so good, how about You showing me for the day, maybe I can catch on better that way."

When I was still orienting at a that LTC facility, that's exactly what I trying to do... see how in the world the experienced were ACTUALLY doing it ALL... but they kept pushing me to "jump in and do it" myself, saying the only way to learn was to do it. Well, I never did figure out how to do it all in good time and was threatened that I'd better figure it out like the others had, but not by watching them, of course. I was scolded for concerning myself with how the others did it (or seemed to not do it) when I should be focusing on how I could do it.

I quit. I don't like quitting, but the environment was not healthy there for me. The other nurses either treated me like a complete dummy for not being able to do it all or seemed to barely scrape by themselves and didn't have any words of wisdom for me, only looks of sad sympathy as they scurried about trying desperately to do what they needed to do.

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I was charting an assessment following a nurse from a previous shift... I noticed that she had charted on the character, color, etc. of this patient's urine. Problem is....Several days before this patient had a...

Bilateral Nephrectomy. Hmmmmm...

This is a very interesting thread.

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Trying to chart everything is downright impossible on some days. Got report last week from nurse "Her heart rhythm is sinus rhythm with PAC's" .............Really I asked? Because she is not on tele. The nurse had charted the ICU assessment as her own after the patient was transferred to our floor.

I put on the ordered tele unit and her rate was 140's while resting.

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:o :(I think that maybe sometimes we have so much pressure on us that we take shortcuts..and what you or I may consider "false charting" another just looks at as getting the job done. I have noticed that the newer nurses seem to stress out more easily, and me I just remember when...I dunno....we had a meeting at my hospital tonight about our staffing and we are allotted as much OT as we want to work. The nurse shortage could have alot to do with some of the problem. Who knows, on my floor we have some horrible nurses that seem to lack any accountability or pride in their work. :crying2:
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