Is this false documentation?

Dear Nurse Beth Advice Column - The following letter submitted anonymously in search for answers. Join the conversation!

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I work for a home healthcare agency as an agency certified trach vent LPN. Apparently they have been pressuring me to document things at the end of my shift before they actually happen in order to be able to hand off the EMR device to the relieving nurse right on the hour. She doesn't like clocking in a few minutes late. So I'm supposed to give up time so she can get every minute of hers? I say l don't chart it until it happens otherwise that is false documentation, am l correct ?

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Specializes in Tele, ICU, Staff Development.

Your use of the word "apparently" implies that the agency (your manager?) has not directly instructed you to pre-chart. If so, you need to talk with your manager for clarification.

Before meeting with your manager, organize your thoughts so you know what outcomes you want from the meeting and what suggestions you have in mind.

Managerial Problem

Not surprisingly, the absence of a clear protocol for nursing handoff set the two of you up for conflict. 

First, time-keeping functionality should be separate from the EMR device. Second, there should be some built-in overlap for shift changes. 

You are correct. Documentation should always be accurate and timely. Documenting events before they occur is a poor workaround for the above problems.

The manager is responsible for:

  • Setting clear documentation and time management policies. I'm sure there's no agency policy titled The Chart Before Care Is Given policy.
  • Encouraging open communication to resolve conflicts before they escalate. Do you have staff meetings?
  • Training on best practices for documentation and time management.
  • Promoting a professional workplace environment.

Solution

What would happen if the three of you sat down cooperatively to devise a solution for handoff? I have a hunch you could come up with some excellent, creative ideas.

You could establish clear guidelines on what's expected of the offgoing and relieving nurses during shift change. This includes when charting should be completed and how much overlap, if any, is allowed at the end of the shift. 

The Bottom Line

Shift change should be reasonable and achievable for both parties. Setting realistic time frames for charting, handoffs, and taking over patient care will help ensure smooth transitions and reduce stress for off-going and relieving nurses.

Best wishes,

Nurse Beth

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