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.

The first ltc facility I worked in, right out of nursing school, it was universal practice for all the nurses to get report, count, and then sign the treatment book, before they ever went out on the floor. I, new nurse that I was, said "but I haven't done them yet!" "you won't have time to come back and sign them later" I was told. They just laughed at me.They were right. You were in trouble if you stayed overtime to do it, you were in trouble if you clocked out and worked to do it, you were in trouble no matter what you did. I am not saying I approve, but that is the way it was.

I am currently in a facility where there are meds, and breathing treatments etc all due at 5pm, I'm supposed to pass trays, hang an IV, supervise the dining room, pass meds simultaneously every night. I have 26 patients, 5 gtubes, 7 diabetics, a trach, 6 breathing treatments (multiple times a day) one man whose chair needs repositioned every hour( and only nursing can do it), another woman whose brace needs to come off or go on every two hours, p cleaning someone's eyes, vitals, lotions, bandage changes, wound care.....next week I am supposed to get a woundvac/gtube added. Speech therapy told me she is going to turn the pleasure feeding of one of my gtube patients over to nursing, three times a day - I said "I don't have time." I am already in there, pouring the food, dropping the eye drops, for 12 minutes each time. Therapeutic feeding takes 20 minutes, at least. Add that to the trach care and just one of the other gtubes (just one of them) and there's an hour already - at med pass time. And I've got 24, count 'em, 24 more patients to go. I am supposed to be off at 10pm and it's not unusual for me to stay until 2am. Nurses in this facility stay for hours after their shift ends to get treatments done, meds passed, etc. It would be impossible to fill out an incident report every time a med was late. None of us would ever be able to leave. This is universal at this facility. I focus on the meds that are time critical - insulin, heart meds, antibiotics, etc - if someone gets their colace with their bedtime meds, they'll live. God forbid a patient actually wants to TALK to me, or needs a hug, or a family member calls, or a doctor's office, or pharmacy shows up. I go without dinner, without breaks. This is true on every shift and every hall in this facility. God forbid you find a rash - it's 45 minutes of paperwork. Skin tear? same thing. If you get a fall and skin tear in one night, don't bother crying, there isn't time. I come in repeatedly to the first shift nurse in tears trying to keep up with it (she's been there 13 years and has resigned, as has the adon, the unit manager, the 2nd shift manager etc) Management doesn't give a damn and I hope there's another level of hell for the people who admit these patients and just stack them up on these halls without any consideration for acuity and adequate staffing. I talked to our medical director about it one night - I said it's my license and yours, not the guy in the admissions office - why don't you have a say in who is admitted here? You are the medical director?! Not the aide who was promoted to admissions director, or the aide who is now facility director. He is going over the facility director's head to corporate, I think. Nurses are quitting right and left and I am looking because I hate working this way. Apparently, the facility director gets a bigger bonus the less staff he uses to run the facility. How he sleeps at night, I do not know. When I've worked outside of ltc this stuff hasn't been an issue. I was transferred here because census was low at another company venture (hospice) where none of this was an issue. There was sufficient staff, sufficient time, etc. Sure, it was crazy sometimes, but not like this. In the midst of it all, there are real people, real patients, real nurses....and I try to hold onto that, to the human contact, and try to make a difference to at least some of them.

I really think nurses want to do right.....

I will blame the employers for driving this.

They must give us more time to do our work........

Specializes in ED.

I have filled out many risk masters with no action taken. I have gone to multiple meetings, requested by myself, to speak with the ED director or manager about a nurse/incident/labs lost/yadda yadda.

The sad thing about all of the previous posts is that it happens all too often. Under staffing, pressed for time, and increased patient loads make us cut corners from time to time. Yea, I have falsified a patients vitals that was in my ED for a toothache or a stubbed toe. I document estimated weights all the time because I cannot get every EMS or straight-back patient on the scale. I am supposed to do hourly rounding AND hourly clinical notes, but in all honesty, when does that happen? On a slow night perhaps. If I am lucky.

Some genius thought it would be a good idea to scan all meds when giving them. Yes, accurate charting and another fail-safe for patient safety, but also yes to time consuming, frustrating when the scanner/badge/med doesn't work properly and not really appropriate for the ED. And then I get chewed out for not complying with policy. How about some of the higher-ups come down and work a shift and scan ALL the meds? Half the time the COWS battery is dead from day shift.

Our scope of practice as nurses is continually widening, yet staffing seems to dwindle, tech positions disappear, and shifts feel like they get longer. There is always an exception to the rule, but knowingly fraudulently documenting that you did something when you did not is wrong. Slap my hand for documenting the tooth ache has a pulse ox of 100%, but I am not charting an assessment that I did not really do. I simply won't document, and if my charge or manager or director wants to ask questions or moan and complain, I will tell them the truth. Yes, the reason the Baker Act ran out of the ED is because the psych rooms were already full, the ED was full, and I had 7 patients to care for and I even pulled a CNA from the floor to be a sitter. I am not going to tackle a patient, that is what the sheriff's office is for. It is not my fault that we are understaffed and overworked. The truth hurts sometime.

To the LTC and nursing home nurses, I give you kudos for what you are able to do. That has to be a depressing job. I know you guys are so understaffed, it is ridiculous. Blame capitalism and greed for these situations. Just one request before you package up a patient and send them my way: an accurate, concise report would be nice, handwritten on paper even, and not 'the patient doesn't look good"; empty the foley bag! Vent over.

I say to each their own. After all, it is your name and license number that is on the line when the attorney's start sniffing.

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.

Of course it is. If it's not true, it by definition must be false.

There may be no harm in a q 2h check. If you can justify it due to the patient's condition/status, by all means chart a q 2h check.

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?

Can't you just write "late entry-neuro check at 12 pm shows patient is alert and oriented x 4," etc.?

With more institutions moving to an electtronic Medical Record, it is becoming increasingly difficult to document "creatively." Although in most EMRs you can go back to an earlier time, the charting will still reflect the actual time the entry was made in the chart. So if you do all of your charting at the end of the shift, you can document those hourly checks on time, but anyone reviewing the chart will see that you did all of your documentation at one time. Our hospital has gotten around this by allowing an explanation for this in the progress notes. We write something like, "Hourly checks done as ordered, documented at..." Of course, we are expected to do what we charted, or we will be looking for a new employer.

Mindlor, you seem to think that every problem with our healthcare system is created by management. I never knew there were so many greedy, evil people in our country who want to make patients sicker and make nurses unhappy just because they think it's a cool thing to do.

I really think nurses want to do right.....

I will blame the employers for driving this.

They must give us more time to do our work........

With more institutions moving to an electtronic Medical Record, it is becoming increasingly difficult to document "creatively." Although in most EMRs you can go back to an earlier time, the charting will still reflect the actual time the entry was made in the chart. So if you do all of your charting at the end of the shift, you can document those hourly checks on time, but anyone reviewing the chart will see that you did all of your documentation at one time. Our hospital has gotten around this by allowing an explanation for this in the progress notes. We write something like, "Hourly checks done as ordered, documented at..." Of course, we are expected to do what we charted, or we will be looking for a new employer.

I work in a large metropolitan medical center. The manager has deemed that our main assessment be done and charted within 2 hours of our shift start time.

Sooo.. I start at 3:00, sometimes need to hunt down several nurses .. running around , trying to get things done so they can go home.

It's not unusual to take until 4:00 to get report.

Then I must assess 6-7 patients. How in the h*ll can I even accomplish that.. let alone enter them into the EMR? Those first 3 hours consist of running around .. eyeballing my patients and putting out fires.

In the perfect world of management dreams... I could leisurely stroll into each room. introduce myself.. fill out the all important white board.. do 6 or7 complete physical exams and chart them.

That is of course.. unless one of those 6 or 7 patients might actually ...gasp.. need something!

You bet I falsely document... I am aware that the actual time I enter anything in the EMR is noted.

Perhaps some of the "watchers" could stop watching .. and help deliver patient care?

Specializes in Orthopedic, LTC, STR, Med-Surg, Tele.
I work in a large metropolitan medical center. The manager has deemed that our main assessment be done and charted within 2 hours of our shift start time.

Sooo.. I start at 3:00, sometimes need to hunt down several nurses .. running around , trying to get things done so they can go home.

It's not unusual to take until 4:00 to get report.

Then I must assess 6-7 patients. How in the h*ll can I even accomplish that.. let alone enter them into the EMR? Those first 3 hours consist of running around .. eyeballing my patients and putting out fires.

In the perfect world of management dreams... I could leisurely stroll into each room. introduce myself.. fill out the all important white board.. do 6 or7 complete physical exams and chart them.

That is of course.. unless one of those 6 or 7 patients might actually ...gasp.. need something!

You bet I falsely document... I am aware that the actual time I enter anything in the EMR is noted.

Perhaps some of the "watchers" could stop watching .. and help deliver patient care?

OMG. I assess everyone within two hours, but if I had to actually document all of those assessments (each and every shift) within two hours, well I just don't know how I'd do it. Sometimes I get in at 7pm and can't get assessments and notes into the computer until 11 or 11:30 pm. Jeeeeez.

Specializes in Pediatric Cardiology.

Can't you just write "late entry-neuro check at 12 pm shows patient is alert and oriented x 4," etc.?

It is a pull down assessment, you can do a comment though. But I don't see the point of writing that it is a late entry, I did the assessment at 12. It is not like I am making an assessment up, at which point I would consider false documentation coming into play.

Specializes in LTC and School Health.
It is a pull down assessment, you can do a comment though. But I don't see the point of writing that it is a late entry, I did the assessment at 12. It is not like I am making an assessment up, at which point I would consider false documentation coming into play.

I guess I was misunderstood. What I meant was, there was many times when neurochecks q15 min cannot be done EXACTLY q15 min and is still documented as if it was done "on time".

Specializes in Gerontology, Med surg, Home Health.

There is a difference between charting something that you've actually done and charting something that you didn't do.

If I actually assess the patient at 10am but don't chart it till 230 that is not false documentation. If, on the other hand, I sign off everything in the treatment book as done but never once left my chair at the nurses' station, that IS false documentation. I'm sorry all y'all have such rotten managers. Perhaps they've never had your job and don't really know is a policy or protocol is realistic.

We've changed many of our protocols and policies to reflect real life. It is impossible to toilet 40 residents every 2 hours so why chart that you are? We customize our care based on what the resident needs so the work gets done and the charting is valid.

PS.I am managment and I've had all your jobs at one time or other. I don't ask the nurses to falsify documentation. We don't hide mistakes since many times they are caused by a systems problem.

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