False documentation... more common than you think.

Nurses Safety

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Scarlette Wings

358 Posts

Specializes in M/S, ICU, ICP.

i love the part "

disclaimer: this is my personal opinion and i hope we can agree to disagree if need be. if you are a perfect nurse, please

do not

read. "

but really, what is the underlying reason you wrote what you did? just curious.

CapeCodMermaid, RN

6,090 Posts

Specializes in Gerontology, Med surg, Home Health.

I can honestly say that in my nursing career, I have never falsified any documentation.

I wouldn't sign off something on the treatment sheet unless I had personally done it.

I signed my meds off when given. I never signed for something I didn't do.

I don't allow nurses who work for me to do it either.

End of story.

Specializes in med-tele/ER.

how come you have an hour window for a calcium chew? I am just curious. If I am going to have to give the med late I just reschedule the med. Does your facility not allow the nursing staff to make the administration schedule?

Specializes in FNP, ONP.

I've been in Nursing for 25 years, and I can say without a doubt I have never falsified a patient record. I am not super nurse, but I am an ethical one. If I didn't do something, or did it late, I documented that and why. I have written things like: "could not turn patient due to her weight and lack of available assistance. Hoyer lift out of service."

Hell yes it upset people. But I'm not going to lie to protect them. I tell the truth, to protect myself and ultimately, the patients.

In my opinion the OP is just making excuses for bad practice; practice which is frankly, indefensible. I hope there isn't much support for it. :( Another reason nursing is in such a state, we cannot even trust our "colleagues."

Amelias

18 Posts

I would NEVER chart ahead of time.... EVER !

lmao mostly b/c I'm always behind

palmsofvictory

37 Posts

I was a veteran for 9 years, teacher for 5 in my previous career. In my experience, a single individual who tries to change systemic problems (to me it sounds like the OP is in that situation) almost NEVER is able to do so through official channels. Official channels are usually a farce and only function practically as overwhelming, endless red tape and deterrents for actual change and/or make shining a light on problems = professional/career suicide. Official channels simply alert leadership to employees who are "dangerous" to the status quo... "thanks for letting us know to put a target on YOUR back, you idiot". I've been in meeting with Generals and Colonels before. You might be shocked at the real reasons they are making the decision they do.

Real change for the better requires either 1) a large group of people willing to speak the truth and demand change or 2) an individual who has some kind of connection or special leverage.

Every time i hear someone say "Have you used official channels of change?", all i can think is: Clueless/naive person.

There are so many examples of this:

1. Insurance companies of all stripes usually have a policy to deny 1st (and maybe more) claim attempts outright because it is mathematically-proven to be good for business. Bottom line: $.

2. When you see suspensions/punishments handed out in various situations, often the appeal process goes to the exact same decision maker eventually (usually after several steps required to follow an algorithm of pseudo-justice... meaningless paperwork, hours of time, etc.) Bottom line: justice isn't really justice.

3. GroupOne (Google it and read). Bottom line: yikes!

4. I've known a teacher that won Teacher of the Year one year and was not asked to return the very next year. (Multiple reasons possibly exist). Bottom line: jealousy, liability

4. Endless other examples (Racism, especially pre-1960s being only one. What do you think would happen to someone who vocally challenged Hitler??? Sometimes breaking rules means you are closer to the true spirit of the matter... think Germans who hid Jews and lied to the Nazis when asked. Watch Schindler's List.) Bottom line: read some history, please

Corruption exists. Finding a fair work environment is RARE! Just talk with teachers, police officers, nurses, Dr.'s, lawyers, et. al. I have no problem with people LOVING it when they find it, but judging other people who have a corrupt work environment is just small-minded and cruel. Many times you don't know how messed up your company is until you are already heavily invested in it. At that point, jumping ship is a complex task. Besides, sometimes it is a more complex dx than "this place is evil." Could be one or 2 individuals within a decent org. Could be a multitude of things. (If you disagree, tell me why so many perfectly sane, decent women simply do not leave abusive relationships? That situation isn't "2+2" to the individual involved... it's "1. Explain the universe. 2. Define evil and explain why it exists."

I had a Master Sergeant friend in the military who told me he achieved more change and did more good things in his career by knowing "dirt" on his bosses than he EVER did by using official channels. He TRIED to use official channels in the beginning of his career and was repeatedly told and SHOWN (read:abused by those with greater power) that, since he had no power as a lower ranking person in his org., being vocal would only make his situation worse. But seeing his boss, the Chief Master Sergeant, at the club with a female who was not his wife... well, let's just say a wise man once said, "Be as harmless as doves and as WISE as SERPENTS." Sometimes the "system" is nothing but a bully. And bullies usually respond to being punched in the face, not asked nicely.

For those of you unwilling to admit/recognize that, for some people, consistently documenting the truth means GETTING fired, rather than AVOIDING getting fired. ... well... try, just try for a second and brainstorm if you can imagine how a person might find themselves in a situation where that is reality. Really think about it. If that doesn't work, keep on trying to Get. A. Clue. I have faith that sooner or later you will get it. Hopefully, i am not wrong.

It is the hallmark of a tiny mind to not be able to understand that, sometimes, when the head is damaged (read:corrupt), the body is 100% paralyzed (read: screwed).

Good day, folks.

justchill, BSN, RN

1 Article; 96 Posts

I'm a student and about to graduate. Always when on clinical, I try to keep in communication with my co-assigned RN at all times even if they aren't the warmest to me. There has been several occasions where I'm talking with while charting (luxury of electronic charts) where I've heard them chart something and say "Ohhh we'll say it was done at this time." If I am late charting or the actual action was late, I never change the time. I also write the time it was performed and time charted. If there is a reason why the actual action was late, I chart why. I feel that if you are honest up to front and hold to your own integrity that when the proverbial crap does hit the fan and something occurs causing you to be late; you'll be much more credible than someone who is always changing times (especially even though on electronic charting they can see when the information was inputted regardless what you change it to).

There was once a nurse who would not do the blood sugar checks and just write down a number in the bedside chart so they wouldn't have to get insulin. One patient (type I none the less) was in the 500's when I checked it later in the day. This was when I was not yet checked off and I reported symptoms to my instructor who went with me to do it. That's blatant falsification.

chevyv, BSN, RN

1,679 Posts

Specializes in Acute Mental Health.

OMG palmsofvictory, you are sooo right on!!! The one who goes on up the ladder is the one I see getting walked out time and time again! This is the real world and if you make waves, there are 20 rns ready to take you place is what I've been told.

I do have a question to those that don't get those meds in within your window and just give it and chart that it was given late......okay...it's a PO located in the chart that states times to give. If you give late without getting a PO to do so, isn't that illegal? For me, I have to call the physician, state the reason, and get a give now one time order. Which is exactly why, unless it's very outside the window I've seen most nurses chart given within that window. How can you wait until management calls you in to explain and be honest when giving it outside the window is illegal? Legally, you should be calling the doc and getting the order to read something about okay to give between such and such time X45 days (ltc)

If that happens a lot and your management gets wind of it from you especially, they will ask you what your problem is so be prepared.

Catzilla

113 Posts

I've witnessed situations were the majority of the staff were either falsifying the records or clocking out (and kept working) in order to complete their duties. When an individual would come along who refused to falsify records or work "off the clock" they ultimately ended up being the one disciplined (or worse), because, you know, "If everyone else can get the job done..."

When the majority of a group resorts to falsification of records or working for free (illegally) isn't that a sign of a major system error? I'm curious, has anyone been in a situation where the lot banded together and refused to change/alter documentation times and then discussed the issues with management as a unified group? If so, what was the outcome?

At the onset, when administrative bureaucracy came up with the requirement to document :

Q 15' checks for ANYTHING

Q 2 hour checks for restrained patients... checking the restraint site, checking the toileting needs, checking the need for continued restraints, checking the vital signs...

We unanimously agreed...

They are MAKING us lie! The very act of initialing all of their precious little boxes .. makes it too time consuming to perform the tasks!

This is not just LTC... it is everywhere.

Any one that doesn't see that .. has their head buried in the sand.

Kudos to you for having the guts to bring this issue into the real world.

Vespertinas

652 Posts

how come you have an hour window for a calcium chew? I am just curious. If I am going to have to give the med late I just reschedule the med. Does your facility not allow the nursing staff to make the administration schedule?
Most don't

mindlor

1,341 Posts

I wish I had a quarter for all the lungs CTA bilaterally and the RRR, PPP that I have seen.

In many cases it was obvious that no one had ever put a stethoscope to these patients chests.......

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