False documentation... more common than you think.

[OnlybyHisgraceRN, ASN, RN]

Disclaimer: This is my personal opinion and I hope we can agree to disagree if need be. If you are a perfect nurse, please do not read.

I have seen many threads on AN about false documentation and while most replies to these threads have been helpful many members feel the need to judge the OP for false documentation.

In my opinion, many floor nurses are guilty of false documentation, so what gives some of you the audacity to judge and berate another nurse.

How many times have you given a medication outside of that "one hour" window but charted it was given on time?

How many times have you documented your assessment at the time it was supposed to be done, when in reality it was done much later or even much earlier.

For my LTC, nurses are you 100 percent positive that your 20-60 residents were turned and repositioned every 2 hours, or that each one of them was toileted every two hours? Yet you will still initial those two initials in that square box.

When I was a nursing student I would often floor nurses "magically" come up with a patients weight, vital sign, or blood sugar and document, knowing that it was NEVER done. I was so quick to judge as a student and thought their license should be taken right away. After working as a nurse, I realized that while I don't condone that behavior I understand it.

If you answered NEVER to all my questions you are either a super nurse or either you work in a place that have perfect staffing, perfect patients, and perfect coworkers.

The purpose of this thread was for us to sit here and evaluate ourselves before we judge someone for false documentation.

I'm not talking about the nurse that is clearly negligent, lazy, and etc. I'm talking about the nurse like myself who provides competent and quality care to patients but faced with staffing issues that makes it nearly impossible to document every single thing as it is being done.

Unfortunately, some of us work in places where we no longer take care of patients but instead we are taking care of the higher ups in their effort to please the state.

Maybe if we can get rid of some of this customer service BS we can actually have more time for proper and precise documentation.

We are saving lives everyday. I rather give a calcium chew tablet 2 hours late than to ignore my patient that has CHF and having SOB.

So the moral of this story is that people in glass houses shouldn't throw stones.

For all of you nurses that never had to participate in "false documentation" I admire you, envy you and hope to be like you when I grow up.

[JenLPN001]

Agree to disagree? How about agree to agree? You nailed it! I work in an Alzheimer's facility and there are days (evenings in my case) where we're lucky to be able to keep our "strippers" from doing a strip tease in the dining room, get everyone fed on time, and deal with the five families we have who seem to think that thier family member is the only person we have to take care of, on top of two med passes, treatments, wound care, four foleys to deal with, seven residents on hospice, etc, etc, etc, etc. Usually I have little post its everywhere reminding me of who did what and when and then, when everything has settled down and all our charges are finally in bed, I sit down and chart, chart, chart. False documentation? Technically. Real life versus the ideal? Most definitely.

[caliotter3]

I haven't been jumped on for charting when I do something if it is out of the window. I would imagine that is because most of the time I chart a reason for the discrepancy.

[OnlybyHisgraceRN, ASN, RN]

Agree to disagree? How about agree to agree? You nailed it! I work in an Alzheimer's facility and there are days (evenings in my case) where we're lucky to be able to keep our "strippers" from doing a strip tease in the dining room, get everyone fed on time, and deal with the five families we have who seem to think that thier family member is the only person we have to take care of, on top of two med passes, treatments, wound care, four foleys to deal with, seven residents on hospice, etc, etc, etc, etc. Usually I have little post its everywhere reminding me of who did what and when and then, when everything has settled down and all our charges are finally in bed, I sit down and chart, chart, chart. False documentation? Technically. Real life versus the ideal? Most definitely.

I used to work in a Alzheimers facility. I know exactly what you are going through...

[BonnieSc]

I do not ever do the things you list. I'm not a super-nurse by any means. I just don't falsify my documentation--as I was taught in nursing school, and long before that, as I was taught by my parents. I find myself in every situation you describe, but I tell the truth about it.

As I said in my response to one of those threads, I've never worked in an environment where I felt I was constantly under the threat of being disciplined for something like giving a med outside of the approved window. I don't feel I can guarantee that I would never falsify documentation, because I don't think you can be sure until you're in the situation. I do know I would be looking for another job as soon as possible.

If I give a medication late, or miss a turn, or something of the sort, it's because I used my nursing judgment to determine that something else was more important--or it's because of a human error that everyone makes in every job. I hate it when I do something like that, but it isn't so often.

If I were called into my manager's office to ask why I did my assessment so late, I would explain. I WILL have a valid, justifiable reason for it, even if it's human error (which is generally forgiven in such cases, as long as it isn't major and isn't habitual). I will never have a justifiable reason for falsifying documentation--lying. How could you say to the face of your manager, your co-workers, your patients and their families, a judge, a jury, "I lied"?

[nurseprnRN, BSN, RN]

why does everybody come to an and ***and moan about staffing in snfs and ltc and i don't ever see anyone saying what they did about this? is there anybody out there who has promulgated some sort of action to effect change in these situations? please, i wanna hear about it! everyone wants to hear about it!

you know, when you make out a variance report ("meds for south wing given two and one half hours late due to new admission assessment," "no weights done on first of the month, insufficient staff," "mds done 4 days early as i will be away on vacation and there is no one to cover me," "foley catheter care on five residents not done this shift, no time due to extended med pass.") it goes to your risk manager. if you are part of a corporate structure, it goes to the corporate risk manager.

risk managers get very cranky about this sort of thing, because they realize that when there are a lot of these, they indicate system-wide risk exposure, and that means money (fines, judgments), and that gets management's attention. if everyone does them, especially if you are in touch with colleagues from the other facilities in your network, you could have an effect for the better.

if you are really ripped about the situation you're in, and you get no response from the risk manager maneuver, you could make anonymous reports to the state. but do something. act like professionals, the professional advocates you are. it's for the residents, see.

[OnlybyHisgraceRN, ASN, RN]

why does everybody come to an and ***and moan about staffing in snfs and ltc and i don't ever see anyone saying what they did about this? is there anybody out there who has promulgated some sort of action to effect change in these situations? please, i wanna hear about it! everyone wants to hear about it!

you know, when you make out a variance report ("meds for south wing given two and one half hours late due to new admission assessment," "no weights done on first of the month, insufficient staff," "mds done 4 days early as i will be away on vacation and there is no one to cover me," "foley catheter care on five residents not done this shift, no time due to extended med pass.") it goes to your risk manager. if you are part of a corporate structure, it goes to the corporate risk manager.

risk managers get very cranky about this sort of thing, because they realize that when there are a lot of these, they indicate system-wide risk exposure, and that means money (fines, judgments), and that gets management's attention. if everyone does them, especially if you are in touch with colleagues from the other facilities in your network, you could have an effect for the better.

if you are really ripped about the situation you're in, and you get no response from the risk manager maneuver, you could make anonymous reports to the state. but do something. act like professionals, the professional advocates you are. it's for the residents, see.

i have made many variance reports in my day for other nurses. it came to a point that i was making them on a daily basis and could not keep up with my work and i would leave work hours late doing these reports. i'm not sure if you've ever worked in ltc but this is where you will find most falsification of records.

greentea i have tried to do something about this. i have contacted the bon in my state with the concerns i had about staffing, and the mega med pass in ltc, and was turned away. the bon doesn't give a damn about nurses. the only time they want to protect patients is when something goes really wrong and a patient suffers. so much for prevention.

i have spoke to obudsman as i felt residents were not receiving proper care at one particular facility.

i have spoke with administrators, dons, and previous coworkers about my concerns at places i've work. it has gotten me no where. so yes, i do come on all nurses to b@#^$ and moan because no one else in the real world does anything.

so next time you accuse me or anyone else for not being professional or a patient advocate take the time to ask first. ummm, okay?

any more suggestions, honey?

[nurseprnRN, BSN, RN]

yeah, since you ask, honey. get out in the real world. of course admin, don, and previous coworkers aren't going to do anything-- they'd have done it already if they were inclined to. all you've mentioned here is just in-house moaning.

i don't see the state inspection people in there, i don't see any corporate risk managers or corporate attorneys in that list. chapter and verse and why it matters (since they might not always know the medicare rules, etc.)

and it's gotta be more than just you.

organize.

[OnlybyHisgraceRN, ASN, RN]

I do not ever do the things you list. I'm not a super-nurse by any means. I just don't falsify my documentation--as I was taught in nursing school, and long before that, as I was taught by my parents. I find myself in every situation you describe, but I tell the truth about it.

As I said in my response to one of those threads, I've never worked in an environment where I felt I was constantly under the threat of being disciplined for something like giving a med outside of the approved window. I don't feel I can guarantee that I would never falsify documentation, because I don't think you can be sure until you're in the situation. I do know I would be looking for another job as soon as possible.

If I give a medication late, or miss a turn, or something of the sort, it's because I used my nursing judgment to determine that something else was more important--or it's because of a human error that everyone makes in every job. I hate it when I do something like that, but it isn't so often.

If I were called into my manager's office to ask why I did my assessment so late, I would explain. I WILL have a valid, justifiable reason for it, even if it's human error (which is generally forgiven in such cases, as long as it isn't major and isn't habitual). I will never have a justifiable reason for falsifying documentation--lying. How could you say to the face of your manager, your co-workers, your patients and their families, a judge, a jury, "I lied"?

You have proven my point. My point was that many times nurses use their critical thinking to take care of more important things, which means not every single med and treatment is done in that window.

So yes, you are guilty to my friend. Unless you wrote yourself up for giving a med outside of an hour window( I've done this).

It is lying when you chart you gave that calcium at 9 am but it was really given at 11 am...

[OnlybyHisgraceRN, ASN, RN]

yeah, since you ask, honey. get out in the real world. of course admin, don, and previous coworkers aren't going to do anything-- they'd have done it already if they were inclined to. all you've mentioned here is just in-house moaning.

i don't see the state inspection people in there, i don't see any corporate risk managers or corporate attorneys in that list. chapter and verse and why it matters (since they might not always know the medicare rules, etc.)

and it's gotta be more than just you.

organize.

i another friend/co-worker wrote letters and spoke to corporate attorneys and even the ceo's of the facility. once again it got us no where, but with a target on our back. sorry i didn't take the time to list every single person i've contacted along with every intervention.

obviously, i can't do anything on my own. the purpose of this thread was for others to see that false documentation is sometimes unavoidable in certain work conditions. that was all. i got out of ltc for these reasons. i couldn't stand it anymore. i'm hoping that my new job will enable me to never have to lie again....

[BonnieSc]

I think I was perfectly clear in what I said. I DO NOT chart that I gave a 9 AM calcium at 9 AM unless I did it. If I gave it at 11 AM, then I chart that I did that. Please don't call me a liar.

[Ladybluebell]

I think everyone does some "creative' charting once in a wile with the workload we have, and manager's breathing down your neck. I would never make up vital signs or anything, but sometimes you need to get creative. I will document hourly rounds because i am expected to, but sometimes i might not really get in to the room that often. I don't consider this as false documentation. If i am in the room q2 instead of hourly and the patient is ok, whats the harm.