New job--charting issue?

[hamdog]

Hi everyone!

I am a CNA and just started my first job as one on third shift last night--I loved it!

Anyways, the girl I was "shadowing" was showing me how to chart on the system and I just have a few questions. She would chart for behavior that she assumed was normal for the pt (even though she hadn't witnessed it). Shw would also chart for things like ambulation, fluids, etc. based on what she assumed would happen when 0600 rolled around.

I understand that charting is a major pain and everyone wants to get it done, but is wise or even ethical to do so when you haven't witnessed the thing you are charting? Something could be abnormal for the day and then you have charted incorrectly.

For example, this CNA charted fully for 2300 to 0700 for a pt that ended up being sent out to the hospital. Now in my opinion the charting would then be considered incorrect since the pt was gone halfway through the shift.

Any experience, ideas, or comments welcome.

Thanks everyone!

[Sun0408, ASN, RN]

What that CNA did was incorrect and could land her in big trouble with her facility as well as the board. She falsified documentation. While it does happen, it is not good practice. Chart what you see ,do, empty, and what amount the pt ate or drank. Only chart what you are responsible for. If you ever have a question, ask the nurse you are working with.

[hamdog]

Thank you--I was thinking along the same lines and I definately do not want to get into trouble!

[JDZ344]

False documentation is very serious. DO NOT copy her example. I would imagine that, since the patient was sent out, she will have been discovered by the charge nurse.