Is it legal to chart for something you didn't do?

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by AmandaBeaverhausen AmandaBeaverhausen Member Student

Specializes in CMA, CNA.

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I work in LTC and was just told to not forget to chart from 3P yesterday. I said, no, I chart from 7P-7A because that's my shift. The nurse said, but it's part of 3-11 shift. I said but we no longer have those 8 hour shifts, AND if I walk in after residents have eaten, I have no way to know their intake. That it's the 7A-7P shift's job. And technically, it's lying, which in healthcare is illegal, right?

caliotter3

38,333 Posts

You are correct.  You were not there at 3 pm, so how can you chart on events that did or did not occur at 3 pm?  Somebody is trying to take advantage of you as a minimum, at worst you are being set up for their failures/mistakes. Stand your ground.

Davey Do

Specializes in Psych (25 years), Medical (15 years). Has 43 years experience. 1 Article; 10,121 Posts

6 hours ago, AmandaBeaverhausen said:

I said but we no longer have those 8 hour shifts

Good, solid stance, Amanda.

I missed 8 hour shifts in the last few years of my career. I think it was Charles Schultz who said, "Winters walk. Summers run".

I would say, "Eight hour shifts ebbed and flowed. Twelve hour shifts were feast or famine".

JKL33

6,381 Posts

It doesn't matter if the shift is 8 or 12 hours or whose "job" it is or which shift someone could say it belongs to. If you did not do it, if you don't know anything about it, if you weren't in the building and were not responsible for those patients at the time in question then yes, it is illegal. It is called falsification of medical records, which are legal documents, for services that are largely reimbursed through government funding, so likely also fraud.

Dare I ask why the heck the person who *was* there at the time in question doesn't think it is their responsibility to chart their care and their assessments?

Regardless, say no. Tell them you aren't arguing about it; it's illegal and fraudulent, end of story.

Medic2RN72, RN, EMT-P

Specializes in Emergency Medicine, Critical Care, Research. Has 1 years experience. 32 Posts

Make sure you document the conversation you had (notebook) incase it comes back up later, so that you will have a record. Do it while the event is still fresh in your mind. Document the specific facts for your protection and easy recall. Always CYA, especially in "high risk" environments. 

JKL33

6,381 Posts

WADL this is not any kind of high-risk situation. This is a goofball who doesn't have a leg to stand on trying to bully someone into doing someone else's work. This sort of thing is not infrequent; there wouldn't be time to take care of patients if it were necessary to also make a record of others' ignorance. ?

Medic2RN72, RN, EMT-P

Specializes in Emergency Medicine, Critical Care, Research. Has 1 years experience. 32 Posts

3 hours ago, JKL33 said:

WADL this is not any kind of high-risk situation. This is a goofball who doesn't have a leg to stand on trying to bully someone into doing someone else's work. This sort of thing is not infrequent; there wouldn't be time to take care of patients if it were necessary to also make a record of others' ignorance. ?

Gotcha! 

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 7 years experience. 1,013 Posts

Wonder how the nurse would react if she was also asked to chart on patient care performed during hours she wasn't present? 

Like others have said, you've done nothing wrong. You're completely right in that it is fraudulent and illegal to chart things you did not do. 

If the nurse continues to ask you to do so, you may want to consider consulting your supervisor.  This nurse may be participating or encouraging others to participate in other unethical activities 

hppygr8ful, ASN, RN, EMT-I

Specializes in Psych, Addictions, SOL (Student of Life). Has 20 years experience. 4 Articles; 4,638 Posts

Remember this phrase. "What you are asking me to do is fraud and not legally defensable!"

It works best when delivered in total deadpan with a straight face.

Hppy

SmilingBluEyes

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis. Has 25 years experience. 20,962 Posts

On 6/21/2021 at 2:40 AM, hppygr8ful said:

Remember this phrase. "What you are asking me to do is fraud and not legally defensable!"

It works best when delivered in total deadpan with a straight face.

Hppy

This is an excellent answer. The simple answer to your question is "NO" it's NOT legal and WILL get you in super hot water.

chare

3,686 Posts

On 6/21/2021 at 5:40 AM, hppygr8ful said:

Remember this phrase. "What you are asking me to do is fraud and not legally defensable!"

It works best when delivered in total deadpan with a straight face.

Hppy

This.  I also find that asking them if they're (insert expletive of choice) crazy works well too.

MiladyMalarkey, ASN, BSN

Specializes in Neuro. Has 3 years experience. 519 Posts

Look at it this way, if something went sideways with a patient, an event occurred or something & you charted for that patient during that time--when you were not present,  you could have a very rough time explaining to the State Board or some litigation attorney or court why you charted something you absolutely had no observation or part of. It's falsifying charting really & could get you into some deep *ish. Tell that nurse you absolutely will not document something you were not a part of or witness to. Not worth your license. You're right in your stance, stick to your guns.

Edited by MiladyMalarkey