Published Sep 21, 2014
SilleLu
150 Posts
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
6,255 Posts
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
2,218 Posts
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.
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
1,004 Posts
We use EPIC & we can't even chart a minute ahead. I would never pre-chart an assessment.
MeganB1983
25 Posts
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
3,530 Posts
Unrelated, but q4 head to toe assessments on a MS floor? That's silly.
Thank you!!!!! Lol
mariebailey, MSN, RN
948 Posts
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
176 Posts
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
20,908 Posts
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).
RNperdiem, RN
4,592 Posts
A lot of the computerized systems won't let you chart ahead. You accept being perpetually behind.