How common is charting ahead in ICU?

Posted

Has 3 years experience.

Say you have to chart a complete assessment q2h...busy at 4 pm, catching up on charting at 6 pm...so charting for both 4 pm and 6pm at the same time...but also "precharting" the 8 pm assessment with the intention of going back if anything changes.

Couple questions -

1. Do you see nurses do this a lot? Is it not a big deal?

2. This is computerized charting...sure you can change the time to 8 pm, but if the chart is audited, they could see you did the 8 pm charting at 6 pm, right?

Me - nursing student in last semester...I understand there is a real world vs nclex world, but wondering where this falls.

Thank you

Altra, BSN, RN

Specializes in Emergency & Trauma/Adult ICU.

Charting events from both 4pm and 6pm shortly after 6pm = OK, if patient care demands meant that there was no time to chart in between 4pm and 6pm.

Charting ahead for 8pm when it hasn't occurred yet = definitely not OK, ever.

As you correctly point out, electronic timestamps make everything crystal clear. How would you defend charting on a patient's condition at a specific time, before the time has occurred? You would never be able to justify that.

Nascar nurse, ASN, RN

Specializes in LTC, Hospice, Case Management. Has 35 years experience.

disclaimer - I have never worked in ICU

Reality is the same across the board -

1. As a nurse manager, I would seriously counsel (write you up) or fire you for blatantly falsifying medical records.

2. Just imagine the legal implications if that patient dies before 8pm.

SilleLu

Has 3 years experience.

Thank you for the quick replies...

I guess if the charting was a couple minutes early but time changed to 8 to make it look 'neat' I wouldn't have thought anything about it...but nearly 2 hours early just to 'get it out of the way' was disturbing, especially considering the pt was doing worse than expected (stable, not deteriorating, but not progressing).

Lennonninja, MSN, APRN, NP

Specializes in MICU - CCRN, IR, Vascular Surgery. Has 10 years experience.

We use EPIC & we can't even chart a minute ahead. I would never pre-chart an assessment.

We use epic and can chart an hour early. I'm on the med surg floor so charting early is hardly an option, I'm always so busy. We do Q4 assessments and if I did my assessment at 2300 instead of 0000 I wouldn't think anything of it to chart ahead (on a stable patient). You are talking about ICU. That's a completely different ball game. They don't have you do Q2's to give you more charting to do. I wouldn't mess with ICU patients' assessments.

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 10 years experience.

We use epic and can chart an hour early. I'm on the med surg floor so charting early is hardly an option, I'm always so busy. We do Q4 assessments and if I did my assessment at 2300 instead of 0000 I wouldn't think anything of it to chart ahead (on a stable patient). You are talking about ICU. That's a completely different ball game. They don't have you do Q2's to give you more charting to do. I wouldn't mess with ICU patients' assessments.

Unrelated, but q4 head to toe assessments on a MS floor? That's silly.

Appropriate documentation takes place as soon as is feasible AFTER care is provided. I'm pretty sure charting BEFORE nursing care is actually provided is falsification of records, & it could have legal consequences.

Muser69

Specializes in Critical care. Has 42 years experience.

The Only thing I sometimes pre chart is that stupid restraint form. It is the only paper form we use and all they care about is if it is filled out. I usually fill it out at the beginning of the shift. Trust me the directors only care if it is completed. Not when or where.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Thank you for the quick replies...

I guess if the charting was a couple minutes early but time changed to 8 to make it look 'neat' I wouldn't have thought anything about it...but nearly 2 hours early just to 'get it out of the way' was disturbing, especially considering the pt was doing worse than expected (stable, not deteriorating, but not progressing).

As a student you should NOT be considering these things. It looks really bad that you change a chart entry made a 1950 that vitals signs are stable no complaints at 2000 when the patient codes at 1955 and is deceased by 2000. You have NO recourse when that chart is audited especially in a court of law.

RNperdiem, RN

Has 14 years experience.

A lot of the computerized systems won't let you chart ahead. You accept being perpetually behind.