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.
Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
Maybe you mean you start the "draft" version of charting ahead of time. For example, assess, take vitals, etcetera early in shift, write the nursing note, but don't save it until the end of the shift, in case anything changes....
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.
I'm curious how you know, at the beginning of a shift, whether or not your patient will remain in restraints for the entire shift?
Intubated patients in soft wrist restraints may well get extubated during a shift, and restraints removed.
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.
Correct me if I'm wrong but you are saying you did your assessment early, at 2300 instead of 0000. But you DID your assessment and charted that you did it at 2300 instead of 0000. Right? Or . . . did you do your assessment at 2300 and chart that you did it at 0000?
This isn't what the OP is talking about though. OP is talking about charting something ahead of time that you have not accomplished yet. Although any kind of charting that doesn't tell the truth is wrong. So, charting at 2300 and lying and saying you did it at 0000 is also wrong.
I've heard too many horror stories about doing this - charted at 0700 that you gave patient's meds at 0800 only to have patient die at 0730.
Charting something that hasn't been done yet is wrong and never should be done.
If you are too busy to chart, something needs to be done about the way your unit is being run. I became a nurse at 40 and one of the things that bugged me was how we didn't stand up for ourselves and get involved in the system to make it better.
I am not a fan at all of electronic medical records by the way. The focus changed from patient care to payment.
(Regarding med/surg . . . .we always charted an assessment with vital signs Q4H)
Don't ever chart ahead. Ever. On any form, any chart, anything that you sign your name to that it is completed. Lots of stuff can happen in a short period of time, regardless if the patient appears stable or not.
Not good practice, and it is not something you can justify. Doesn't matter what unit. It is hard to explain that you were signing out meds at 8pm, and in fact, you charted you were assessing a completely different patient at the same time. And that stuff DOES get noticed.
Even the nurse who said they fill out the restraint form at the start of the shift. Never, ever good practice. Cause when a patient who is restrained sues for--lets say--nerve damage in their hands that renders them disabled, that anyone signs off "all is well" when it is not can really get themselves into hot water.
I always wondered why nurses would chart both patient's assesments at the exact same time. I don't know if they were worried that beacuse we're supposed to assess every 4 hours, both patients needed an assesmenty charted at exactly 7,11, etc. Obviously, it is impossible to be in two places at once so I always charted my assesments in real time...say, one at 7:05 and the other at 7:20, but always when it actually occurred. Situations can and do change with no warning, at any time and on any patient. Charting ahead is terrible practice that will eventually cause you major problems.
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.
Not sure what you meant...but just in case to clarify: I am not considering doing this. I have not done this. I witnessed my nurse do this and found it disturbing. I wanted to make sure my concern was valid.
Even the nurse who said they fill out the restraint form at the start of the shift. Never, ever good practice. Cause when a patient who is restrained sues for--lets say--nerve damage in their hands that renders them disabled, that anyone signs off "all is well" when it is not can really get themselves into hot water.Just don't do it.
That poster mentioned that it was a paper form so that leaves me to wonder if it is assumed that if something goes wrong after the form has been pre-charted, they can just pitch that form and flil out another. In my facility, when any form is printed out it has the patient's name/medical record #/etc. on it. The system knows exactly how many forms have been printed out for any given patient. So, an attorney reviewing the chart may see that the physical chart only contains 67 pieces of paper, but in reality 72 existed at one time and are therefore unaccounted for. That leaves some explaining as it appears that portions of the patient's medical record have been destroyed. I guess one could always use a blank pre-printed form and put a patient's sticker on it and that would leave no trace that it ever existed, but why not just do things the right (legal) way and then you have no reason to worry.
ICU, we do Q4 assessments. We also use epic and it won't allow us to chart in the future. The only way I could see of doing this would be to chart something for the current time then use the option to copy the entire column to 8p later.
As many have said this is a bad, bad thing to do especially with the unstable folks in ICU. What if they die before then, get transferred, etc.The record will show all! Just not worth it, and with epic it really doesn't take all that long to catch up after things settle down.
This is NOT okay and this is not the norm. They are doing something extremely wrong. I've worked in ICU and understand the struggle of keeping up with documentation, but there is no excuse.
If you're ever looking for a way to save time, this would not be the right way to do it. Just think, if a nurse is in the habit of charting ahead, there is no way he/she will remember to make changes every time. You could be providing excellent hands-on care, but getting caught charting ahead won't only get you in trouble regarding that one instance, your personal integrity would probably be considered questionable.
It's not possible for me to chart ahead on our computer system nor would I want to. I TRY to chart in real time as much as possible but I rather chart late than falsify the records.
I have known of those that got fired for charting on the rounding logs ahead of time. I mean they actually filled out the entire log for the 2 hour checks:no:.
vintagemother, BSN, CNA, LVN, RN
2,717 Posts
Maybe you mean you start the "draft" version of charting ahead of time. For example, assess, take vitals, etcetera early in shift, write the nursing note, but don't save it until the end of the shift, in case anything changes....