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.

Specializes in Certified Med/Surg tele, and other stuff.

We scan our meds and our charting is computerized. It documents when we pass meds and do notes, so no hiding anything.

I would be willing to bet a million dollars of money that i don't have that EVERY SINGLE ONE on this thread has creatively charted... so just STOP with the hypocrisy![/quote']

Why do you use the phrase "creatively charted" instead of "lied"? And what makes you think so? I have never had any reason to lie. NOT because I never make mistakes.

Specializes in Emergency, Telemetry, Transplant.
I would be willing to bet a million dollars of money that i don't have that EVERY SINGLE ONE on this thread has creatively charted... so just STOP with the hypocrisy![/quote']

What the heck does 'creatively charted' even mean? If it means falsified documentation, then, no, I have not done it.

If it means do an assessment at 0800, chart it at 1200 (but timed for 0800) then, yes, I have do that. I don't credit myself with any creativeness, just charting at the time something was done.

Probably not a wise bet to make.

Specializes in ICU.

Nope. Never once have I falsified a chart. Sorry.

No, it is not a personal affront, it is an observation. In several threads, you have stated that different issues are due to management's refusal to staff appropriately. This leads me to think that you believe all managers and administrators are greedy and evil. Yes there are some power hungry selfish administrators, but this is true in any profession. Most managers and administrators do care about patients and staff. But we are forced to function within constraints applied by state and federal governments and regulatory agencies that require more documentation and that we meet stricter standards of care. With ever decreasing reimbursement and higher acuity patients, it is becoming more difficult to provide good care and remain fiscally responsible. It is very frustrating to see staff struggling to meet patients' needs. This is why I spend most of my mornings on the unit helping with care, then stay until six o'clock every night to complete my administrative duties.

Well,

Long before I went to nursing school I went to management school and hold a degree in management. 1st day they taught us that if there was a problem on our team, it was our responsibility......

That can be read as yes, every problem is a management problem. That does not mean the manager is a bad manager, it means it is their responsibility to fix the problem.

Its none of my business of course, but I would be interested to know if you are employed by a for-profit or not-for-profit facility....

At my facility a lot of people need to be fired....sadly many of them are chums with the nurse manager........so what we have now is good nurses transferring off the floor or simply walking......

At my facility staffing is horrible, pts are treated like cattle and it is a management problem......I hope and pray your facility is different......

Please note that I do not get paid by my facility, it is where I am doing my preceptorship.....

The discussion is meaningless without some sort of consistency in use or agreement/understanding re definition for "false documentation".

It doesn't make a lot of sense to compare someone fabricating blood sugars, vital signs and weights (which is where this thread started) to a duly noted three hour time lapse between performing a timely assessment and documentation of the findings.

well,

long before i went to nursing school i went to management school and hold a degree in management. 1st day they taught us that if there was a problem on our team, it was our responsibility......

that can be read as yes, every problem is a management problem. that does not mean the manager is a bad manager, it means it is their responsibility to fix the problem.

at my facility staffing is horrible, pts are treated like cattle and it is a management problem......i hope and pray your facility is different......

please note that i do not get paid by my facility, it is where i am doing my preceptorship.....

the fly in the ointment is this........

more often than not, in the healthcare industry, administrators and board members determine the organizational goals, priorities, and budgets etc; not managers.

based on the confines of that framework, managers then make division level decisions on budgets/policies/programs/staffing etc.

if senior administration does not identify something as a problem, it is not a problem :). what you are now observing is not an aberration, it is more the norm than not in this field.

staffing concerns, and the resulting consequences, rarely make it to the priority problem list.

Specializes in OB.
I would be willing to bet a million dollars of money that i don't have that EVERY SINGLE ONE on this thread has creatively charted... so just STOP with the hypocrisy![/quote']

You do not know me nor do you work with me (or I'd assume most of the other posters here) so I'd suggest you refrain from stating what you think I or they would do as fact and accusing us of hypocrisy.

Speak for and be responsible for your own actions only.

Specializes in Gerontology, Med surg, Home Health.
I would be willing to bet a million dollars of money that i don't have that EVERY SINGLE ONE on this thread has creatively charted... so just STOP with the hypocrisy![/quote']

You'd lose the bet. Please don't call anyone a liar or a hypocrite, since obviously you've never met us or have the experience or knowledge to speak about our practices.

If you are still a student, I'd suggest you lose your holier than thou attitude quickly.

I don't lie and I don't falsify medical records....ever.

I would be willing to bet a million dollars of money that i don't have that EVERY SINGLE ONE on this thread has creatively charted... so just STOP with the hypocrisy![/quote']

Ah yes...the "everybody does it" argument. Wasn't true 100 years ago when it was being flung about, isn't true today.

The discussion is meaningless without some sort of consistency in use or agreement/understanding re definition for "false documentation".

It doesn't make a lot of sense to compare someone fabricating blood sugars, vital signs and weights (which is where this thread started) to a duly noted three hour time lapse between performing a timely assessment and documentation of the findings.

I completely agree.

Specializes in LTC.

Meh, I do it. Never making up vitals, but hey- I have 30 people to chart on.

I KNOW Ms So-and-so's sugar is going to be sky high after she just ravaged that cake, I'll jot down- "BS elevated, covered per sliding scale. Appetite good." However, my lot of 30 only changes every so often, so I've become familiar with them. It's not a "Lie", it's an accurate prediction based on her history, and current activity. ;)

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