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Discussion

False documentation?? Did I break the law ?

Charting gives me anxiety. Did I break the law ?    Am I allowed to chart (I’m currently a CNA) a bowel movement or vitals of my patient even IF another co worker or nurse took the vitals or took them to the bathroom ? I have major anxiety and alot of times will leave aspects of charting blank out of fear of doing something wrong. I’ve had nurses take my patient to the restroom and say “so and so had a large “ and I’d just leave the charting blank since I didn’t see it myself. Then I’ve had a co worker help me with my vitals and although I don’t technically believe she gets the respirations or asks for the number of pain level of a resident I’d document it under my name. (I was orientating  when this happened ). I feel like I’m breaking the law. Do I need to confess to my employer that I documented vitals that another co worker obtained for me ??  

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    Talk with your employer, though I doubt they would me much help, it will be interesting to see what anyone else thinks.  But since I stuck my head in here; I would be comfortable taking the co-workers word for any of this, unless you think the person has an issue with accuracy or truth.  

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