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

Nurses General Nursing

Updated:   Published

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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?

I prefer sarcasm! 

"I ve heard it was you that left the foot long in the toilet and they had to call maintenance to remove it because it wouldn't flush" or " Was it you that cleared out the cafeteria with that terrible fart?" then walk away! 

Ask me a stupid thing and I will give you a stupid answer. Always leave stupid people puzzled and they will leave you alone. 

I work at a hospital and many RNs will chart what they assume, believe, imagined, guessed (take your pic) what a CNA had did for a patient. Even if the CNA did do the task, the RN charting that it was done is stating that they did it themselves. Perhaps it is petty, because the point is that the patient got the care it shouldn't matter who did the task. It just bugs me

Specializes in Critical Care.

There is nothing that prevents you from charting something "you didn't do", and actually it's pretty common, so long as the charting includes that you didn't personally perform the task or didn't directly observe something.

If what you're being asked to do is chart what the patient reports they ate for lunch then there's nothing that prevents you from doing that.  "Patient reports they ate 50% of lunch".  

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