Charting, done by the amazing psychic nurse

[DesiDani]

The gifted nurse who charts what he/she never did, seen, or acquired about.

Does it ever catch up to them?

[ProgressiveActivist, BSN, RN]

No. As long as the boxes are checked no one cares.

If the family complains about serious negligence it might be addressed. They also have the option to file a complaint at cms.gov

Don't make it easy for her to falsify charting by giving her your assessments.

The least that a nurse can do is give the meds and I have met two in my career who didn't even do

that. Patients complained management knew and chose not to do anything about it. The nurse who reports gross negligence is labeled a problem.

And shady employers actually prefer shady nurses.

[chevyv, BSN, RN]

It never seems to does it! Sad

[RNdynamic]

Usually it doesn't catch up with anybody, because usually it isn't a big deal. I've known a ton of nurses who "write in" vital signs, restraint documentation, CIWA scores, pain scores, and other things. In nursing, "writing in" is another term for "making up." I've done it a few times myself.

[amoLucia]

... And shady employers actually prefer shady nurses.

Ewww. This is scarey but methinks much truth be spoken!

[DesiDani]

Well when you have to account for charting and you have some made up stuff, what do you say then? I've seen RNs fired for filling in stuff. Not good.

[RNdynamic]

You don't actually tell them you made stuff up. You just tell them it was true at the time you documented it.

[DesiDani]

How do you explain if it doesn't match with reality. False charting is just wrong, better not to put anything down. Ill maybe just a CNA, but I'm surprise that so many RNs are justifying an obvious wrong unprofessional act.

[ProgressiveActivist, BSN, RN]

The EMR is a billing platform. Admin will penalize nurses who dont chart false info about turns assessments restraints etc. Typing redundant information even takes priority over pt care in some hospitals. Reality is that we often dont have time to do both. It is a difficult choice so dont judge until you are put in that position.

[RNdynamic]

What the above says. Our manager has nurses from our unit who randomly audit our skin and restraint documentation. If you miss a q2h turn because you're too busy, you get in trouble if you leave it blank because then you didn't turn the patient. So what should we do? Tell the truth? Type in "pt was not turned because nurse was too busy to perform turn?" Yea, that'll go over well.

We're also supposed to reassess pain scales one hour after we give pain meds. If you assess after one hour, it's considered a missed assessment and the manager sends you an email about it. What are you supposed to do if you can't get back to the patients room within one hour? It's either write in a number or get in trouble.

Our restraint documentation also has a check box for q2h toileting and q2h passive ROM on the restrained limb, and you're expected to check it ff every 2 hours. Do you honestly think nurses have time to perform q2h passive ROM on restrained limbs?

Don't blame nurses for making stuff up. Blame the environment that fosters these solutions.

[ProgressiveActivist, BSN, RN]

Someone posted that their institution told nursing to stop writing free text progress notes as those are unnecessary and hurt "productivity. " I am paraphrasing what she said.

I have to wonder if throwing a nurse under the bus is part of their grand plan.

[kbrn2002, ADN, RN]

This is another one of those grey areas that may have more offenders in some areas of practice than others. I work in LTC with computer EMARS, the crazy amount of silly but according to the powers that be necessary orders that need to be checked off astounds me. So yes, I check all those orders when I have time. If I waited until the end of the shift, which technically I should do I would never get done anywhere near on time.

Our nurse mangers that enter these orders are aware of this practice and try to place all those non-med orders on the EMAR so they can be clicked off on the computer at any time during the shift instead of making them time specific for end of shift. Technically doing this pre-charting is wrong, but we all do it. Then again we are doing charting on 24-28 residents so anything that saves time is done, and clustering all the charting we can when there is time to do it makes sense to us.