False Documentation

[Daytona.67]

I am an LPN and I have a question about false documentation. I know it is illegal to chart ahead on a patient. My question is this...When your supervisor comes to you and says that some nursing assessments and progress notes are missing on certain days. They tell you to go back to that specific date and see if you were working. If you were and it was your patient that day, do your assessment and progress note for that day. Would this be considered "false documentation" since the documentation isn't done in real time? How can you document on a patient you haven't assessed in 3-4 days and put accurate information? I am worried about this since a nurse was recently fired for false documentation.

[sallyrnrrt, ADN, RN]

"Depends, and not just for incontinence, " i guess it is worst to not do an assessment or note when you were suppose to, late entry, when you truly know the data although not ideal, is more acceptable, than no documentation.......

[floridaRN38]

I was told in the hospital where I work u can go back to a pts chart and chart on it up to three days after.

[dudette10, MSN, RN]

Charting with a limit up to three days after your assessment seems to be the norm. You don't chart what you see today, you chart your assessment that was done three days ago with a "late entry" notation.

"Real time" is the goal, but doing so is often difficult. Although I know some that have, in a pinch, charted on a patient the day after the assessment was done, usually the longest delay is to at end-of-shift, usually after report has been done.

The bigger question is, why didn't you chart during the same shift or at end-of-shift?

[nurseprnRN, BSN, RN]

I was told in the hospital where I work u can go back to a pts chart and chart on it up to three days after.

This old wives' tale and others like it have been around forever. There is no magic number. However, the further out you are, the less reliable your memory will be. If there is ever a need to audit a chart, a note written today on last July will look sketchy, but a note written today for yesterday, not so much.

The way to chart a late entry looks like this:

February 3, 2014, 3:15pm. Late entry for February 1, 2014, 7-3. Blah, blah, blah, blah. Jane Smith LPN

Critical point: If you cannot remember details, never never never make them up. Chart only what you actually remember. Never let anyone noodge you along into writing something you don't know of your own personal knowledge. if it's not in the chart, it's not in the chart. Next time, make time.

[BuckyBadgerRN, ASN, RN]

I think it would be considered false documentation if you charted an assessment that you didn't really do. Charting an assessment a couple of days after the fact, to me, would be considered a late entry and not a falsification.

[Hoosier_RN, MSN]

as everyone else has said, note it as late entry for such and such date, and the details as you remember them. No legal issue with that

[Sam J.]

as everyone else has said, note it as late entry for such and such date, and the details as you remember them. No legal issue with that

Oh?

"Lawyers- you can't live WITH them, and you can't live withOUT them." -Unknown author

[caliotter3]

Whatever the circumstances, don't make it a habit to be charting a lot of late entries. If you find yourself getting behind in charting, it is better to just bite the bullet and stay over to complete your charting after your shift is done, even if you are told to clock out and do it on your own time. Eventually habitual charting discrepancies can lead to a heavy nail for your employment coffin. They never seem to pay that much attention to it until someone gets you in their sights, then they find every little misplaced comma and make you pay.

[bagladyrn, RN]

caliotter - I'm going to disagree with one part of your post here - Do not clock out and continue to chart or work on the unit in any manner. If you are not on the clock you are not covered by workman's comp, or malpractice for anything that happens while you are there. In fact, if you are "off the clock" you are not even legally entitled to be in the patient's chart as you are not responsible for the care of that patient at that time.

[caliotter3]

I have been told on more than one occasion by my employer that I am required to finish charting on my own time. This even came up during the hiring process. Based on the fact that I needed a job, I complied with the employer's demands. Do I recommend it, of course not. But I have seen plenty of other nurses who needed their jobs too.

[Chica22]

True story. It's getting more common.