Falsifying nursing documentation

[jenack]

Falsification of documentation to satisfy Joint Commission Requirements for Stroke designation. My nurse manager demanded that the charge nurse and patient care facilitator enter documentation on stroke patients that they did not care for. This type of documentation is a felony however it is often required of nursing staff anytime Joint commission, magnet or any other regulatory agency comes to our hospital. This time the manager is having nursing enter neuro VS and Glasgow coma scales every hour on stroke patients when the nurse caring for the patients entered them every 4 hours as ordered by the physician. We were told all ICU patients get Q 1 hour neuro checks regardless of what the physicians orders are. The manager is not asking the nurses who took care of the patients to enter the information in the medical record she is making the charge nurse and patient care facilitator create documentation that does not exist. What is the best way to handle this situation? If the nurse refuses they fear being fired, if they falsify documentation they will not only loose their license but could be sent to prison.

[Green Tea, RN]

On the floor where I used to work, similar thing happened to me. The manager demanded to document a certain assessment (pertaining to the speciality) q4 in the first 24 hours of post-op to satisfy one of JC requirements. Sadly, the nurses on the floor was falsifying documentation because it was impossible to perform the assessment that often due to heavy workload. It is one of the reasons why I left the floor.