My first Post! Question re: MAR documentation

[barbarake21]

Hi everyone:

I am a nursing student and will be taking the NCLEX-LN on 6/28. Hopefully I'll be finishing school and taking the NCLEX-RN in January.

But I currently work (part-time) as a 'Medical Technician' in an Assisted Living Facility. This is not a licensed position, I merely had to take an 8 hr. course and pass a simple 10 question test (both done through the facility itself). I've been working there 8 months.

I took the month of April off from work because of school. When I came back on May 10th, I noticed that some of the other techs were now filling in a column on the back of the MAR that we had never used before. I asked one of the other techs about it and she said that, when giving a medicine PRN, we were now supposed to check on them within two hours to see if it had been effective.

Fine, no problem. I'd been taught to do that in school and had been doing it anyway, albeit unofficially. So I started documenting it.

On May 17th, I noticed that some techs were also putting down the time they checked the patient (even though there's not a column for that information). I started doing it too.

In the beginning of June, the administration had a meeting and told us we (the techs) all had to go back and add in the time we checked from the first of the month through the 17th.

I have a problem with this. It just seems wrong to me. None of the other techs have a problem with it, I seem to be the only one resisting.

Am I wrong? Should I just go ahead and do as they request?

[nightmare, RN]

Well,I would have great difficulty remembering a thing like that so to all intents and purposes you would be falsifying documentation if you put in a time that was not the correct one.

[barbarake21]

Thank you for your quick response.

I can't remember the times either, I'd have to make them up.

What I'm worried about right now is that one of the other techs called me this morning and said that she had heard out paychecks would be held back until we 'fixed our errors'. (Everyone else went through the MARs and added in the time but evidently at least some missed a couple.)

The administration is in a panic because DHEC is all over them and coming in for an audit this week sometime. Evidently the more errors, the bigger the fine. (At least that's what someone told me.)

They only started the course/test thing about four months ago. Would you believe they found that one of the med techs could barely read?!?!!? But she'd been there a long time and 'knew' what patients got what. They

stopped her passing out meds for several months but are so short-handed they now have her doing it again!!!!

[egglady, LPN]

Once again, there is more to "passing meds" than just spooning them in. Unlicensed people have no business (or education) passing meds.

[CrazyMommy, BSN, RN]

So what you are trying to say is that some of the CNA's in your facility can pass med's? I can understand checking on the pt's and recording it, but not passing med's. I had a similar thing, where I was working in a Skilled Nursing Care Unit at my hospital. Almost at the end of the shift the charge nurse told me about those sheets, that I needed to initial them even though I did not go in their room and did the care that was mentioned on the paper (like skin assesment, etc.). It was my first time working there. So I refused and the nurse said all you have to do it initial it, I never did and she told me to take it to the nurse that was in charge of those pt's. I wouldn't do it if I was you!!! You'd be lying, if you can't remember.

[AprilRNhere]

I was always told in LTC that we legally had 24 hours to chart an incident. If you can't remember something- DEFINATELY don't chart it.

[caliotter3]

You may find it common to be asked to "fix" paperwork, especially around the time that an inspection is about to take place. You have to decide for yourself whether or not you are going to comply with the request. If you can remember something, then you are not falsifying documentation, except for the time of making the entry. If you don't remember doing something, that is a different story. Either way, if you get caught doing something like this, you can be in trouble. One thing a fellow nurse told me about something similar, "Well, do you agree? If you don't, then don't do what they're asking you to do." I've seen nurses go back at the end of the month and fill in their "holes" many times. If they don't do it on their own, then medical records or whoever else does the checking asks them to do it. It's a lot easier on the individual if they check their own work and make necessary corrections by the end of the shift. This is one of those areas in nursing where you will see deviations from "the book". Doesn't make it right, just the way things end up getting done.

[vballmanrn]

I would not chart it. It's falsifying [sp] a document. If they are holding back your check because you won't do it then I would look for some other place of employment. They obviously don't have your best interests in mind. Besides, do you really think they are going to stand behind you if a med error occurs or a patient has an adverse reaction? There is a reason why you, me, and everyone else who aspires to be a nurse has gone through nursing school and has taken the NCLEX. I would seriously reconsider working for that organization.