Filling in MAR holes

Specialties Geriatric

Published

Only working PRN in a LTCF now I came to work to find someone had filled in my initials on some missing holes in the MAR. They are obsessive about having all spaces filled in, but they shouldn't have filled in my initials. Also, if you do miss some spots, they make you fill it in at the end of the month. I also disagree with this d/t not being able to verify administration.

Anyone else have this problem?

Laura RN:nurse:

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We have a nurse who has a special job just to do chart audits and I just get sick of the "love" notes.

I think there is too d%$m many things to fill in and sign.

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Specializes in Geriatrics, ICU, OR, PACU.

In my facility, we do a MAR swap at the end of each shift--the nurses are responsible for checking their wing partners. Since we have three carts on sub-acute, the unit manager checks the third MAR. If a hole gets missed, then it stays missed. Having someone fill them in, or having a nurse come in days later to fill them in, is not only a terrible practice, but illegal. Can you say "falsification of documentation"?

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Specializes in LTC/SNF, Psychiatric, Pharmaceutical.
Only working PRN in a LTCF now I came to work to find someone had filled in my initials on some missing holes in the MAR. They are obsessive about having all spaces filled in, but they shouldn't have filled in my initials. Also, if you do miss some spots, they make you fill it in at the end of the month. I also disagree with this d/t not being able to verify administration.

Anyone else have this problem?

Laura RN:nurse:

Someone correct me if I'm wrong... but couldn't someone else filling

YOUR initials into an official medical document be considered falsification... or even forgery?

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Specializes in LTC.

My facility is obsessed with the "holes" as well. We end up with "post-its" all over the mars asking that we fill them in. Wouldn't state just love that? Also, we are told if state does come in, we should drop everything and rifle through the mars to make sure the post-its are taken out. ??? I personally do my best to make sure I sign out, but things happen. Interestingly, the latest "rule" is that if we don't sign out a prn in the back of the mar, we will get a med error. Soooo, never mind the holes... I would certainly take exception to someone else initialing for me. That sounds illegal on many different levels. Good luck with your facility. It sounds as inventive as mine.

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This is wrong. Refuse to do it. The facility I worked in also tried to do this.

Whenever I had to work the floors, there were times that not everything got done. So I didn't chart it. Asked the LVNs on the floor and they admitted to signing all the spaces even when they didn't get things done because the DON required it. You do not want to get into a lawsuit and have this come out. If you can't get everything done, there is a reason and the system needs to be changed.

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Specializes in ICU.

i've known of 2 nurses that got terminated for "altering" a medical record.......if i found out my initials were placed in a blank hole, i'd error them out.......and let the chips fall where they may. :smokin:

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Specializes in LTC/SNF, Psychiatric, Pharmaceutical.
My facility is obsessed with the "holes" as well. We end up with "post-its" all over the mars asking that we fill them in. Wouldn't state just love that? Also, we are told if state does come in, we should drop everything and rifle through the mars to make sure the post-its are taken out. ??? I personally do my best to make sure I sign out, but things happen. Interestingly, the latest "rule" is that if we don't sign out a prn in the back of the mar, we will get a med error. Soooo, never mind the holes... I would certainly take exception to someone else initialing for me. That sounds illegal on many different levels. Good luck with your facility. It sounds as inventive as mine.

So how do you document PRNs?

Every facility I've worked at slaps post-it notes all over blank MARs/ADL holes. They freak out about them around the time they're expecting the annual State survey. One center even mandated that the charge nurse had to check the ADL books end of every shift... and there was a spot in the ADL books where the charge nurse was required to initial that the ADL books had been checked and completely documented by the CNAs. It was hard enough to get all your work done as it was WITHOUT that 30 extra minutes of documentation! What is all this supposed to prove, anyway?

I work in at a plasma center now, and we actually get noted by QA on a daily basis for documentation errors, They post the number of QA errors every employee has had for the entire month. This is because, if certain things are not signed off on, FDA and German regs actually require us to destroy units of plasma, which is a big pain in the company's bottom line.

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Specializes in LTC/SNF, Psychiatric, Pharmaceutical.
This is wrong. Refuse to do it. The facility I worked in also tried to do this.

Whenever I had to work the floors, there were times that not everything got done. So I didn't chart it. Asked the LVNs on the floor and they admitted to signing all the spaces even when they didn't get things done because the DON required it. You do not want to get into a lawsuit and have this come out. If you can't get everything done, there is a reason and the system needs to be changed.

There is a reason facilities do this - strictly for covering their own bee-hinds, not the staffs'. They can show a State auditor that their documentation shows everything that's supposed to be done IS done, and if something like this came out, they could claim the staff was falsifying documents, in an attempt to absolve the NH from blame for a system and staffing that does not allow for acceptable standards of care. How lovely for them.

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Specializes in Gerontology, Med surg, Home Health.
We have a nurse who has a special job just to do chart audits and I just get sick of the "love" notes.

I think there is too d%$m many things to fill in and sign.

Like it or not what we do must be documented. If a patient has a bad outcome because a med wasn't given it will be traced back to the nurse who didn't give the med. That NURSE will be held responsible. I always double checked my MARs as a staff nurse and suggest to my nurses that they do the same thing.

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Specializes in LTC, Hospice, Case Management.
Like it or not what we do must be documented. If a patient has a bad outcome because a med wasn't given it will be traced back to the nurse who didn't give the med. That NURSE will be held responsible. I always double checked my MARs as a staff nurse and suggest to my nurses that they do the same thing.

No kidding. I have been preached to for 20 some years, "not documeted not done". And in 20 years I have never been told that it was alright to just leave something undone because "I didn't have time". Wow, would I hate to have to convince a jury why I left holes in my documentation records or why I didn't do something. Talk about leaving yourself wide open to losing a license. It really doesn't take that much time to double check yourself. And sure something might still get missed but it should be rare and not some common error with tons of holes to fill in at the end of the month. Get real!

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Specializes in LTC.

I am very good when it comes to filling in MAR holes at the end of the night (specially meals), but yesterday I had such a horrible night 2 days in a row that, I came to conclusion I had go home and what ever it was missing was going to be completed on Monday! I know I gave everybody their meds, meals, and etc because as I finish giving meds to one patient I highlight their name on my report sheet (it means I'm done with him or her in regards to MAR):)

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