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.

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. ;)

Wait-I want to be sure I understand you. Do you NOT take your clients' blood sugar but treat it with an insulin sliding scale because you know this patient so well that you've decided it's not necessary to actually take her blood glucose? Or are you saying you chart giving insulin before you actually get around to doing it because you are confident of the eventual outcome? And then later on you take the blood sugar and give the insulin based on the actual blood glucose level?

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.....

You are right, as a manager, any problems on my team are my responsibility. But the answer is not as simple as just adding more staff. In fact, if you look at NDNQI, Solucient, and HCAHPS data, you will see that often the best staffed hospitals do not always have the best outcomes. I feel as if we are hijacking this thread. If you would like to continue this discussion, we can do it by PM, or start another thread

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. ;)

WOW.... just WOW!

Specializes in LTC and School Health.
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.

It means doing your assessment or giving a med, etc. outside the window and charting as if it was done "on time" . Never happened to you, that's great!

Specializes in LTC and School Health.
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 agree that late entries are not "creative charting or falsifying records" What I meant in my OP is not every assessment ( i.e. q 15 hr neuro check) is Completed at that interval, thus nurses will check they did one at 15 minutes but was really minutes later. Just saying.

Specializes in LTC and School Health.
Nope. Never once have I falsified a chart. Sorry.

Don't be sorry, that is wonderful! I'm sure you've made mistakes in your career and thank goodness you never had to do this. Wonderful!

Specializes in LTC and School Health.
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. ;)

Definitely don't agree with this. I don't judge you either, as I'm not perfect like some of the nurses on this board.

I would suggest, not doing this.

Specializes in LTC.
wait-i want to be sure i understand you. do you not take your clients' blood sugar but treat it with an insulin sliding scale because you know this patient so well that you've decided it's not necessary to actually take her blood glucose? or are you saying you chart giving insulin before you actually get around to doing it because you are confident of the eventual outcome? and then later on you take the blood sugar and give the insulin based on the actual blood glucose level?

no, i look up, see my lol with a mountain of chocolate cake and frosting, figure she's going to be high- and then check and cover. the exact number is in the mar- but not the chart at the desk. i used to save all of my charting for the end of shift, but our facility literally forces you out immediately after the last med pass. they cannot understand, if my last pass begins at 9pm, why on earth would i be staying until 10?!

but no- i'd never guess a blood sugar and cover without checking. sorry for the confusion. ;)

Definitely don't agree with this. I don't judge you either, as I'm not perfect like some of the nurses on this board.

I would suggest, not doing this.

Just because some nurses assert that they do not falsely document does NOT in any way imply that they are saying they are "perfect" and it is unfair and misleading to suggest that they do.

but no- i'd never guess a blood sugar and cover without checking. sorry for the confusion. ;)

whew-that's good to know. i'm glad you clarified or you might have been the recipient of a fair amount of well deserved outrage!

Specializes in LTC.
Whew-that's good to know. I'm glad you clarified or you might have been the recipient of a fair amount of well deserved outrage!

I know! x.x

I felt terrible, haha.

Specializes in Emergency, Telemetry, Transplant.
Just because some nurses assert that they do not falsely document does NOT in any way imply that they are saying they are "perfect" and it is unfair and misleading to suggest that they do.

Thank you! I am certainly not perfect, but I also do not willingly commit fraud.

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