False documentation... more common than you think.

Nurses Safety

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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.

For folks who like to believe you've "never" deviated from policy and have "always" done the "right" thing in your 5,000 year career... well, I suppose there is a snowball's chance that you're making a "truthful" statement, so I won't call you a liar. I will say i highly doubt your "always's and nevers".

I suppose ALL of the people in prison who say they're innocent are telling the truth also. And I'm sure whenever you speed on the highway (which, of course, is NEVER for some of you bwaaahahaha), you IMMEDIATELY drive straight to a police station and notify the authorities that you've broken the law and request that they write you an unlawful speeding citation as soon as they can. And you say please and thank you, too. The world wouldn't be the same without you, for sure.

So, for all of those people who are out there maintaining the dignity and integrity of the nursing profession despite all of the "bad, evil" nurses you are forced to work amongst, (*standing ovation*) i have a scenario/question:

Suppose tomorrow, your unit manager informs you:

"Leadership has decided to make a couple of minor changes on our unit that you need to be aware of and that you will be expected to abide by.

1. Due to budget shortfall, unfortunately we have been forced to let go of our unit secretary and all of our PCTs effective immediately.

2. Your shift patient load will increase by 2 patients.

3. You will now be required to have each patient fill out a "shift feedback survey". You will turn these in to the unit manager at the end of every shift. Both the diligent completion and content of these surveys will be considered when your performance reports are written.

We regret having to make these changes, but I can assure you they are necessary. You, of course, will be expected to continue to perform at the highest level."

My question is: You will be able to perform in an excellent manner without "falsifying" any documentation, right?

(By the way, if your answer is yes, management will interpret this to mean the workload is reasonable since you are able to handle it. After 2 weeks, we will be adding +1 to the shift patient load. Ad infinitum.)

Good luck! :)

Specializes in LTC and School Health.
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.

I don't call you a liar. I want to work at a place like you do. Where you can practice honest nursing, and have time to chart as you go along. Good for you !

Specializes in LTC and School Health.
I've been in Nursing for 25 years, and I can say without a doubt I have never falsified a patient record. I am not super nurse, but I am an ethical one. If I didn't do something, or did it late, I documented that and why. I have written things like: "could not turn patient due to her weight and lack of available assistance. Hoyer lift out of service."

Hell yes it upset people. But I'm not going to lie to protect them. I tell the truth, to protect myself and ultimately, the patients.

In my opinion the OP is just making excuses for bad practice; practice which is frankly, indefensible. I hope there isn't much support for it. :( Another reason nursing is in such a state, we cannot even trust our "colleagues."

I respect your opinion. I'm not making up excuses. I've have never made up weights and blood sugars and etc.

When I did give a med late I wrote up the incident report, contacted the doctor and etc. Justifying giving a med late doesn't make it any better? Did you contact the doctor, family, NM and etc after you justified the error?

Where I've worked giving a med late was grounds for a write up and etc. whether it was justified or not.

The purpose of this thread I guess was to let others know that they are not alone when it comes to being creative with documentation and that other nurses should not judge.

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.

yup, get's management's attention, and they come up with an innovative solution, generally involving giving the nurses yet another form to fill out.

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.

bahahaha! right. like nurses can get together on anything. there's always the few that will just suck it up and do whatever management tells them to do. and depend on the few vocal ones to get in trouble and change things. but because the quiet do gooders won't get behind them, the vocal ones get told, "well nobody else is complaining!"

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.

if there's not time to chart accurately, there's sure not time to chart incident reports for every single thing.

Specializes in LTC and School Health.
At the onset, when administrative bureaucracy came up with the requirement to document :

Q 15' checks for ANYTHING

Q 2 hour checks for restrained patients... checking the restraint site, checking the toileting needs, checking the need for continued restraints, checking the vital signs...

We unanimously agreed...

They are MAKING us lie! The very act of initialing all of their precious little boxes .. makes it too time consuming to perform the tasks!

This is not just LTC... it is everywhere.

Any one that doesn't see that .. has their head buried in the sand.

Kudos to you for having the guts to bring this issue into the real world.

I definitely agree. I thought it was me who had my head buried in the sand. I guess I was the only one bold enough to bring it to the real world....

Specializes in LTC and School Health.
I wish I had a quarter for all the lungs CTA bilaterally and the RRR, PPP that I have seen.

In many cases it was obvious that no one had ever put a stethoscope to these patients chests.......

100 percent correct. In LTC we used a check off system. One nurse charted that patient had a great appetite but was NPO.

Specializes in LTC and School Health.

[/size]yup, get's management's attention, and they come up with an innovative solution, generally involving giving the nurses yet another form to fill out.

bahahaha! right. like nurses can get together on anything. there's always the few that will just suck it up and do whatever management tells them to do. and depend on the few vocal ones to get in trouble and change things. but because the quiet do gooders won't get behind them, the vocal ones get told, "well nobody else is complaining!"

if there's not time to chart accurately, there's sure not time to chart incident reports for every single thing.

i agree. i worked at a facility where me and another nurse fought hard to make changes. we both became targets. we were bullied every day. finally i quit, and the other nurse got fired. the nurses that didn't say anything, still got jobs.

i've heard nurses say, " its no bother, i need this job"

For some ppl, this sums it up! hahaha

Specializes in PDN; Burn; Phone triage.

"Leadership has decided to make a couple of minor changes on our unit that you need to be aware of and that you will be expected to abide by.

1. Due to budget shortfall, unfortunately we have been forced to let go of our unit secretary and all of our PCTs effective immediately.

2. Your shift patient load will increase by 2 patients.

3. You will now be required to have each patient fill out a "shift feedback survey". You will turn these in to the unit manager at the end of every shift. Both the diligent completion and content of these surveys will be considered when your performance reports are written.

We regret having to make these changes, but I can assure you they are necessary. You, of course, will be expected to continue to perform at the highest level."

Has this actually happened to you or to anyone that you know of?

Specializes in Orthopedic, LTC, STR, Med-Surg, Tele.

We scan all of our meds, so no BS-ing THAT anymore. I must be lucky though... the only time anyone ever got on my case was when I forgot to chart Percocet given, and since it was a narcotic it was a cause for concern.

No. This is an exaggerated example of the fact that many ppl (not just nurses) are being asked to do too much these days. (Saw it in the teaching field, see it with my wife and friends in their careers... speech therapists, PTs, etc.) But we can't just keep pretending that it's not happening. I think the OP understands this and is looking for others who are thinking the same thing and willing to say it.

We are reaching a breaking point, like the founders with the tyrannical British king.

As pertaining to workloads (nursing and otherwise), time is not magical. It is a limited resource. You can only do so many tasks in a set amount of time.

If you are a personal assistant to someone and they give you a shopping list and $100, you can only buy so many things for $100. No matter how much they want you to or threaten to fire you, you can't keep adding items to the list and still come in under $100. You either have to start buying really cheap goods (reduce quality/time of care for each pt), take some items off the list (reduce case workload / # of pts), buy only some of the items on the list and lie to the boss (if they will not listen to reason and keep on demanding everything on the list) and hope they don't notice some items are missing (get "efficient" with documentation), buy all the items on the list but use your own credit card (clock out and finish paperwork on your free time til 2 hours after your shift is over), or tell them to shove their job up their #%$ and find a new place to work.

It is an allegory. or whatever that would qualify as.

If someone gives you a hairbrush, a 2-liter of Dr. Pepper, and a pack of gum and says "You have 3 hours to build me a Corvette or you're fired"... well, they deserve a kick in the nuts at that point, don't they?

Good day, friend. :)

Specializes in Pediatric Cardiology.

If I do a neuro check (we do them Q4H) at 12PM but do not get a chance to chart until 3PM, is it "false documentation" if I change the time to reflect when I did the actual assessment?

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