False documentation... more common than you think.

Nurses Safety

Published

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 PICU, Pediatrics, Trauma.
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 must comment on reporting...whatever term is used, "Incident Report", "Unusual Occurrence", and the like...I fully agree with you about it's importance and the potential for information gathered to be useful. And I too once thought about it the same as you described. Now maybe I'm a little jaded, but here goes...

"They" always say it shouldn't be looked at as something that can cause a punitive action. "They" say it isn't about you personally, as much as it is about looking at trends and correcting problems. In theory, that is correct. What I personally have experienced contradicts this. I was one who was very responsible about completing these reports, and also one who made a point of accurately charting and when needed, made a note to explain the reason why something was not done at a particular time and so on...Then, BAM! The manager, who was protecting herself and the institution, chastised me for it saying something to effect of..."Every time I turn around there is another incident report from you." She implied that I was somehow inept and there must be a problem with me, which frankly was not the case. In fact, after experiencing a situation where I had made a mistake in a previous job, I had come to be rather "hyper-vigilant" regarding charting/documentation as a rule in order to try to avoid what I went through previously where I didn't have enough details in my charting from that night to adequately defend myself and/or explain the circumstances leading to the error. What I experienced is no different than what most nurses experience, no matter the specialty or setting. We all keep the balls in the air with more work to do than what is reasonable within certain time frames. For example, when you have 4-6 patients who have medications, treatments, whatever all scheduled on a standard time regimen, it is IMPOSSIBLE to simultaneously do 4-6 Head to toe assessments, VS, give each patient medications (often multiple) and the safety checks involved, do general safety checks in each room, etc. all within 30 minutes before or after the hour. Not to mention, help one to the bathroom, give a PRN med request, answer questions, gather supplies, or whatever comes up. What's more, if you accurately document each intervention at the exact time it was actually done, you would have chaos for charting. It would be that much more to keep up with all the exact times. Maybe I'm too OCD now!

It is pretty much universally accepted that we have the hour window for medication administration, but we do not have the same for all the other things we do as far as timing expectations are concerned. So, either we use the default time and not be accurate/truthful, or we enter the actual time things were done and then potentially look like we aren't keeping up. I don't know the answer.

Specializes in PICU, Pediatrics, Trauma.
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?

I hear ya and high five ya!

Specializes in PICU, Pediatrics, Trauma.
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....

I know how frustrating this is. You really did do more than most. Kuddos to you! The target on your back is something I can relate to. And BTW, it's not just in LTC, it is everywhere. Even in Critical Care with 1 or 2 patients, believe it or not. The administrations' expectations are unreasonable just about everywhere....but especially corporate owned institutions. I find, once again, we are all talking about short-staffing.

The topic may have a different name, but it seems all our difficulties fall back on this issue time and time again.

Specializes in PICU, Pediatrics, Trauma.
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."

Whoa! That was unnecessarily harsh. I don't believe anyone here is suggesting out and out lying. My take on this is the timing of certain things, not if they were done or not. Read my post to understand the point. It is impossible to be in 4-6 places at once. And, we are held accountable to these time constraints whether or not it is even reasonable. I don't know where you have worked, or when for that matter, but Nursing these days is FULL of tasks, responsibilities, etc...that add up more and more each day, while the patient acuities rise, and the numbers assigned are the same...no matter how busy or time consuming the patients may be. And when we even tactfully, respectfully, and reasonably bring up our concerns, we are labeled as difficult, or we are considered inept somehow because "everyone else" is doing it. The truth is that NOT everyone else is doing it. We all have the same difficulties. We are discussing how to change this or what our experiences are.

Specializes in PICU, Pediatrics, Trauma.
I was a veteran for 9 years, teacher for 5 in my previous career. In my experience, a single individual who tries to change systemic problems (to me it sounds like the OP is in that situation) almost NEVER is able to do so through official channels. Official channels are usually a farce and only function practically as overwhelming, endless red tape and deterrents for actual change and/or make shining a light on problems = professional/career suicide. Official channels simply alert leadership to employees who are "dangerous" to the status quo... "thanks for letting us know to put a target on YOUR back, you idiot". I've been in meeting with Generals and Colonels before. You might be shocked at the real reasons they are making the decision they do.

Real change for the better requires either 1) a large group of people willing to speak the truth and demand change or 2) an individual who has some kind of connection or special leverage.

Every time i hear someone say "Have you used official channels of change?", all i can think is: Clueless/naive person.

There are so many examples of this:

1. Insurance companies of all stripes usually have a policy to deny 1st (and maybe more) claim attempts outright because it is mathematically-proven to be good for business. Bottom line: $.

2. When you see suspensions/punishments handed out in various situations, often the appeal process goes to the exact same decision maker eventually (usually after several steps required to follow an algorithm of pseudo-justice... meaningless paperwork, hours of time, etc.) Bottom line: justice isn't really justice.

3. GroupOne (Google it and read). Bottom line: yikes!

4. I've known a teacher that won Teacher of the Year one year and was not asked to return the very next year. (Multiple reasons possibly exist). Bottom line: jealousy, liability

4. Endless other examples (Racism, especially pre-1960s being only one. What do you think would happen to someone who vocally challenged Hitler??? Sometimes breaking rules means you are closer to the true spirit of the matter... think Germans who hid Jews and lied to the Nazis when asked. Watch Schindler's List.) Bottom line: read some history, please

Corruption exists. Finding a fair work environment is RARE! Just talk with teachers, police officers, nurses, Dr.'s, lawyers, et. al. I have no problem with people LOVING it when they find it, but judging other people who have a corrupt work environment is just small-minded and cruel. Many times you don't know how messed up your company is until you are already heavily invested in it. At that point, jumping ship is a complex task. Besides, sometimes it is a more complex dx than "this place is evil." Could be one or 2 individuals within a decent org. Could be a multitude of things. (If you disagree, tell me why so many perfectly sane, decent women simply do not leave abusive relationships? That situation isn't "2+2" to the individual involved... it's "1. Explain the universe. 2. Define evil and explain why it exists."

I had a Master Sergeant friend in the military who told me he achieved more change and did more good things in his career by knowing "dirt" on his bosses than he EVER did by using official channels. He TRIED to use official channels in the beginning of his career and was repeatedly told and SHOWN (read:abused by those with greater power) that, since he had no power as a lower ranking person in his org., being vocal would only make his situation worse. But seeing his boss, the Chief Master Sergeant, at the club with a female who was not his wife... well, let's just say a wise man once said, "Be as harmless as doves and as WISE as SERPENTS." Sometimes the "system" is nothing but a bully. And bullies usually respond to being punched in the face, not asked nicely.

For those of you unwilling to admit/recognize that, for some people, consistently documenting the truth means GETTING fired, rather than AVOIDING getting fired. ... well... try, just try for a second and brainstorm if you can imagine how a person might find themselves in a situation where that is reality. Really think about it. If that doesn't work, keep on trying to Get. A. Clue. I have faith that sooner or later you will get it. Hopefully, i am not wrong.

It is the hallmark of a tiny mind to not be able to understand that, sometimes, when the head is damaged (read:corrupt), the body is 100% paralyzed (read: screwed).

Good day, folks.

You are my new hero! I was naïve with a capital N until I finally got it at the expense of "way more than I bargained for". Hanging in until I figure out the next step.

Specializes in PICU, Pediatrics, Trauma.
I'm a student and about to graduate. Always when on clinical, I try to keep in communication with my co-assigned RN at all times even if they aren't the warmest to me. There has been several occasions where I'm talking with while charting (luxury of electronic charts) where I've heard them chart something and say "Ohhh we'll say it was done at this time." If I am late charting or the actual action was late, I never change the time. I also write the time it was performed and time charted. If there is a reason why the actual action was late, I chart why. I feel that if you are honest up to front and hold to your own integrity that when the proverbial crap does hit the fan and something occurs causing you to be late; you'll be much more credible than someone who is always changing times (especially even though on electronic charting they can see when the information was inputted regardless what you change it to).

There was once a nurse who would not do the blood sugar checks and just write down a number in the bedside chart so they wouldn't have to get insulin. One patient (type I none the less) was in the 500's when I checked it later in the day. This was when I was not yet checked off and I reported symptoms to my instructor who went with me to do it. That's blatant falsification.

Please do note the difference between all out negligence, literally falsifying documentation and lying, to occasionally using the default time to chart a minor or inconsequential task. 2 completely different things and as a new nurse, it is so important for you to follow orders as completely as possible and as honestly as possible. My posts on this topic are as an experienced nurse who knows, with a reasonable amount of certainty what is very important VS inconsequential. We are discussing how many of us have had our feet held to the fire when we have been truthful and explain why we were late on doing something, or even didn't get a chance to do something at all when we were overwhelmed with all we had to do. I think we all are NOT happy about this. We are trying to navigate our way through circumstances that are not reasonable. Please be truthful about your care and charting.

Specializes in PICU, Pediatrics, Trauma.
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".

Yes, more like ...One was done 14 minutes later, and one was done 18 minutes later. I get it. This type of thing happens all the time. We are not robots and neither are the patients.

Specializes in PICU, Pediatrics, Trauma.
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?

No. Personally, I don't see how the time you chart what you did has anything to do with what time you did it. They are two different tasks. Come on now...

Specializes in PICU, Pediatrics, Trauma.
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.

Yes. Awesome, but you are the exception and very rare in deed. Your employees are lucky to have you. However, it doesn't solve the problem, but the band-aide makes the boo-boo feel better. I am not making light of what you do, believe me. I just find it so wrong to hold the nurse accountable, and expect the impossible. I know so many who have been wrongly chastised, fired, or reported to the BRN for errors made and then have their whole career destroyed. So management in your position are not the cause of the circumstances, but administrations who continue to have unreasonable expectations from the nurses are. If one were to explain what you have explained about the government mandates etc...and then say..."We know we are asking the impossible, and we understand it is impossible. Therefore, we will not hold you the nurse solely responsible for this and we will all do our best to provide the most important care for our patients."...It would be more fair. But, I'm not holding my breath.

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

Mine too, this is where I'm sitting here scratching my head wondering how in the heck anyone falsifies med administration or documentation in the computer age. Time stamps, people. Time stamps. FTR, I don't falsify. I chart what I did when I did it, and I don't chart it if I didn't do it. Simple.

Just btw, this thread is 4 years old at least. Things change rapidly in the EMR world. There's a good chance the original problem looks significantly different now.

But the original issues are part of the reason I am now an RN Clinical Analyst and can actively do something to help nurses work/chart efficiently. And I am very happy about that.

Specializes in M/S, LTC, Corrections, PDN & drug rehab.
Just btw, this thread is 4 years old at least. Things change rapidly in the EMR world. There's a good chance the original problem looks significantly different now.

What is with all these old posts coming up from the dead?

+ Add a Comment