Fraudulent charting?

DixieRedHead, ASN, RN · Jan 25, 2012

Is omitting pertinent information which explains a patient's decline, such as: "pt was found without oxygen on for unknown length of time", "pt was found without dressing on wound...", "Air mattress malfuntioning, new pressure wound identified, maintenance notified of malfunction and new mattress implemented...", "Medication not available from pharmacy and was not given and patient's BP reading 13 hours after last dose of medication is ___/___." To me these observations cover my butt as to why there is a decline, and triggers my own memory as to what really went down that day when reading it months later if such a thing ever comes into question.
I have been told by the ADON and the DON that such charting raises a red flag for state to dig into the chart further and look for other things and open a can of worms. I have been asked to omit this pertinent, relevant, truthful information from my charting so as not to incriminate the facility. In doing so doesn't it provide the opportunity to incriminate myself and/or my license? So, in general omitting the truth is basically a lie, isn't it fraudulent to exclude information from charting?

1." O2 sat 50%, O2 restarted at Xlpm per min. O2 sat increased to X %." (Your judgement not required. There could be many reasons 02 not in place. That is a personnel/ policy matter and not to be discussed in the chart.)

2. Pressure area , stage 2, 5 cm x 3.5 cm identified on resident's buttock. Insert treatment started. Log need for required maintenance log, and follow through (that's on you) to make sure that it is fixed.

3. Circle med on MAR, turn mar over and chart reason and response when due.

Oh, and make a personal note for yourself in a little notebook. Be certain to note who you contacted, and their response. Then follow through again.

paddler · Jan 26, 2012

Something isn't sitting right in my gut, and I'm sure it must be just because I am misunderstanding. So, I anonymously called the BON and asked the same as above, and they said yes, it is fraudulent to omit information that pertains to the patient that may effect their well being when orders are not being followed. Probably the only time it would come into question (and put my license in jeopardy) is if there was harm done to the patient and there was an investigation and I was questioned. It comes back to the "If you didn't chart it, it didn't happen" rule. Bottom line for me is, I don't want the facility to get dinged by state because of charting I do. I would certainly lose my job if that occurred, so of course there is my own butt to be concerned about. However, I am also concerned with documenting specific things that are not happening that SHOULD be, for the best interest of the patient too. If the state finds that to be red flags, well isn't it rightly so?

pnurse68 · Jan 26, 2012

I am not so sure that such documentation would cover your butt. If I am a surveyor, I am asking the nurse who documented as above..."Unknown lenght of time? When was the last time YOU saw the resident?" Mattress malfunction same thing and no one cares who fixed it, just that it got fixed. Your mat. log will be your proof if you need it. As far as the BP meds, 13 hours between administrations would be visiable on the MAR and by drawing attention to it, you also open your self up to the question of "what did you do about it". RN Supervisor aware is not going to do it either. The next question would be "do you have a policy that states only the Supervisor can call the pharmacy".

I understarnd your DON's concern. Ensuring the best care for the resident is paramount however, you do not know how long the o2 was off, could have been 2 minutes or 2 hours. You dont know how long the mattress was down, or that the ulcer was avoidable.........

Caring for residents is a team effort and takes all nurses and aides involved. The cover my self thing usually dosnt work. At least in my experienc.

debRN0417 · Feb 1, 2012

It is all how you say it. You have to be honest and thorough in your charting and not leave out pertinent details, however, how about "Resident found without O2- list sats- document starting the O2 and at what rate-document your full assessment of the resident and that you notified the MD and RP.

Why would you even document that you found a wound without a dressing? I mean if you have orders for it and unless you assess the wound and there is a change from the last time, then would you just not replace the dressing and document "dressing replaced to wound" and whatever else you need to say. Dressings come off all the time. If you have reason to believe someone was not doing their dressings then you should speak with the DON.

Blood pressure ___/___. Document what you did . If it was circled on the MAR that the med was not given and an explanation written why it was not administered at the time, then it is not your butt that would be in a lurch unless you were the nurse who did not have the med available and did not notify the doctor and did not call the pharmacy for a STAT delivery. I would fill out an unusual occurrence report and notify the DON.

I understand your feeling like you need to cover your butt, but if you were not on duty when it happened, then you would not be questioned, however if your signature is at the end of a note like that, you will be the first in line to be interviewed about it....

Long Term Care Columnist / Guide · Feb 1, 2012

I've been a floor nurse, an RCM, and a DON, and I can tell you there is rarely, if ever, a need to volunteer information that a state surveyor's going to jump on. Simply document what you saw and what you did to fix it---never suppose or assume anything that didn't occur in your presence. For example, in the case of the pt. with a new pressure ulcer, you'll want to save the "air mattress was deflated" for the incident report, which is an internal document that's not really supposed to be fodder for surveyors (although they can, and often will, ask for it when they come across an issue). In the chart, simply note that a new pressure ulcer was found on pt's___________ that measures __________cm and has ________ drainage etc., describe what you did to treat it and that the MD and family were notified.

The same goes for nearly every patient situation you'll come across in your career. You want your documentation to be complete and thorough, but there's a fine line between defensive charting and that which will hang you and your facility. It takes a while to learn, but eventually you'll understand the nuances and be able to tailor your documentation to frame each incident in the best possible light without being dishonest or omitting details that are truly germane to the issue. Don't hand the State the weapon they'll use to beat you over the head.......if they want the information, it's best to make 'em work for it a little.

Sparrowhawk · Feb 1, 2012

It's not what you say, it's how you say it.