Nurse inputting false documentation?

Was there a PCA assigned to those patients? I am a clinical assistant and responsible for all VS. All the information goes on one flow sheet in the computer and it does not say who took the VS. It just shows the time it was done and what they were.

We've come across this a few times this semester. A few examples: meds were charted as given in the morning when they were given 8 hours later (patient almost got a double dose of meds from the student who thought the meds had been given in the morning), a dressing change that was charted as done twice in one day and had not been done at all, and another who had said vitals were taken prior to med pass and the RN had never even set foot in the room until she brought the cup of meds in (and there were things like BP meds). We let our instructor know for the exact reason you stated (if something happened and it was our patient...which in every case a student was assigned to that patient). What our instructor did with the info, I honestly don't know. Good luck to you!

Unfortunately this hospital has been on a hiring freeze for the past year, so they do have PCAs but not any on the L&D floor. Sad because the ladies could have really used the extra help.

We've come across this a few times this semester. A few examples: meds were charted as given in the morning when they were given 8 hours later (patient almost got a double dose of meds from the student who thought the meds had been given in the morning), a dressing change that was charted as done twice in one day and had not been done at all, and another who had said vitals were taken prior to med pass and the RN had never even set foot in the room until she brought the cup of meds in (and there were things like BP meds). We let our instructor know for the exact reason you stated (if something happened and it was our patient...which in every case a student was assigned to that patient). What our instructor did with the info, I honestly don't know. Good luck to you!

Thank you for your input! I noticed a few other inconsistencies in the charting as well.. I'll tell my instructor when I hand the data collection in Wednesday - casually and non-threatening of course. Our instructor used to work on this particular floor so she's friends with a lot of these nurses.

Hopefully our next day is better!!

I agree with just casually mentioning that you saw inconsistencies in the charting of patients you witnessed care for and leave it at that. CYA and call it a day. There could have been someone else collecting vitals that you weren't aware of. It doesn't sound like it from what you describe, but who knows. At the end of the day, your conscious will be clean and you will be covered is this does end up being a problem later.

The facility i'm at has a floater CNA that only takes vitals for patients. They aren't assigned to any floor, the just spend their shift collecting vitals and charting them. I have only seen them once during my clinicals, but they were there each time. Maybe a set up like that in the facility you were at?

Seasoned nurses do things in ways that differ from students. I'm not sure how far into nursing school you are yet, but I bet you would be surprised at the amount of careful time management that most nurses possess. You head to the bathroom, an interesting experience down the hall or are checking the computer for the most recent labs -- and your preceptor nurse has done a full head to toe assessment!

While you say that your instructor is friendly with a lot of nurses on the floor -- that make come back to bite you the ASS, sorry to say. Friendship in nursing goes pretty deep and you may develop a bad reputation as being a whistleblower--- especially if you have no facts to base allegations on.

Maybe a better idea would be to say "Is it true that you grow extra arms and legs as a seasoned nurse? I've noticed my preceptor nurse does things that I've not seen her do!" This can open up a conversation and give you some insight.

Has anyone else every come across this? Today we were in a different hospital so we were on "observation" only protocol for a L&D Hospital. We were each assigned a nurse to follow and then followed them to do their assessments in the morning. I followed my nurse to her patient's rooms and watched their assessment techniques and wrote some notes down for our following day where we will be doing assessments. For our patients we are assigned we are to complete data packets. Nothing huge - I mean it's a lot - but it's more searching and digging through the computer to find the information to come up with nursing care plans. Well when I went into the patients charts I had been assigned I noticed that the nurse had input blood pressures and pulse vitals. The problem is the nurse didn't do these things. Not once did I see her pick up a blood pressure cuff and not once did I see her taking the pulse of the infant or mother (she listened to their hearts but wasn't looking at any form of time clock). I thought maybe it was an error, but then when I checked on my other patient I noticed the same thing. I witnessed these assessments. And we come on the floor right as report is being given so I know she didn't do these things before I came, and I shadowed her all day, so I know she didn't do them after. I know she acts under her own independent license, but I feel really uncomfortable witnessing something like this and then seeing the documentation in the computer. What if something was wrong with that patient and I'm on as one of the individuals that provided care for that day? I don't want to take the fall or risk my future license because of false documentation. Has anyone else run into this? Should I tell my instructor my concerns? I know this is normally not the case.. but still.. I'm working really hard for my future license. I don't want to mess it up.[/quote']

When I worked on the floor the PCT would take the vitals and hand them to me on a vital sheet. I charted the vitals in the computer when I did my assessment. It wasn't false documentation, the task was delegated to the pct and I charted. Same thing with blood sugars and a lot of other things. I would chart urine output and stool character, I was not always the person that measured the output or cleaned up the BM but I still had to chart it and I trusted the information the pct provided me with. Same with information the respiratory therapist and physical therapist report. They do their own charting but that doesn't mean I wont chart "dyspnea with exertion" just because I did not personally witness it. It does mean that when I do my assessment that I will say to the patient, Jill PT mentioned you got really short of breath in PT today and your oxygen level went down" and go from there. Then I can check the dyspnea with exertion box and include some free text from my conversation with the patient "patient states no dizziness or blurry vision but did feel short of breath" or whatever they say to me.

I would be really careful accusing a nurse of false documentation without proof. If you wonder where the information came from you might me better served asking "hey I noticed vitals charged in your assessment, how does it work on this unit do the pct's get them for you, do you chart them from the monitors? How do you find time to do it all? How do you handle delegating, did it take you a long time to get good at it?! Sound interested and enthusiastic and I am sure you will get answers. And if the nurse did happen to be lying about vitals (which I am doubtful about/hopeful is not the case) maybe she will think twice when she realizes an impressionable nursing student noticed.

What's the problem? In clinical we had to do our own vitals anyway so we wouldn't be even using the nurses.

How is it risking your future license?

When we passed meds we had to do vitals immediately before. No using the pct's or the nurses.

I noticed this past rotation on occasion they would put the best of what they saw. Like, if we were called into a room because a PCT noticed an O2 in the 80s, but after a minute of the patient stopping activity and doing nothing but breathing, it would go back up to low 90s. I didn't question it, but it bugged me. Wouldn't it be important to put both numbers? Also pain. If someone says they are having intermittent but moderate pain, wouldn't it be good to document it? My recent facility doesn't because it triggers some sort of investigation if there isn't an intervention for pain, even though the person says the pain wasn't happening that second. This one I did ask about, and while I understand not triggering protocols, isn't it important for providers reviewing the chart to see that there is an issue of pain? IDK. My final conclusion was that this is a new facility for me, I am very, very new to all of this, and I really don't know all of the reasons for all of the things that happen. My job was to learn and observe.

I wish I could say this was unusual, but what I have seen as a clinical instructor would make your heart stop. Usually I told students to bring these issues to me, and I dealt with the appropriate supervisor nurse to nurse. I have witnessed, the magical self-changing drsg, the medication charted at 0900 and found in the Pyxis at 1600, bilaterl pedal pulses on a unilateral BKA, and fundal checks on a postpartum hysterectomy. Talk to your instructor without making any assumptions or accusations. Sadly, not only are nurses run ragged, but many are far too ready to cut corners due to their own laziness and then tell students "this is how it is in the real world". It isn't if you are a decent nurse.