I'm an RN and was hospitalized for a few days recently. The hospital staff did not know I was an RN. Towards the end of my stay I asked one of the nurses to look at my chart. Being the curious George that I am, I looked at the nursing narrative and was shocked (alright, shocked is a little over the top, surprised?) at how many lied about assessing "this" or assessing "that" and/or the activities they perfomed. Some said they inspected my skin for bedsores, some said they assessed my wound, a couple said they provided me some education, some said they assessed my pedal pulses, one said they did catheter care (I didn't even have a Foley!). The amount of lying that went into the documentation was quite astounding. It wasn't just one particular nurse, it was most of the nurses. It was as if they were pulling things out of mid-air. This posting has no other purpose other than to share my experience. I always chart what I actually do... call me old fashioned. I didn't mention anything because I know how busy the job can be, and I'm not one to cause commotion if it can be avoided. I know that it is possible to mix up patient care, but it occured way too frequently to be a mix up.
I agree with all of you it is so wrong. But don't you think it is very hard to take care of 15 patient at the same time and be accurate all the time. Lower the ratio between cna's and patients . then complain if you still get poor care!
I suppose lying is a bit harsh. How about fluffing the records?
Falsifying documents especially ones that are legal such as medical records is ILLEGAL and should be grounds for having one's license revoked.. Documenting a linen change when you know you didn't do it is wrong but not dangerous. Documenting you assessed something on a patient when you actually didn't is wrong and unethical. A high CNA to patient ratio does NOT justify lying about a set of vital signs. If anyone does such a thing, they shouldn't be a CNA or a nurse.
a friend of mine (who is a LPN) went to the doctors office bc she was having blurry vision and fatigue and thought she might have high BP, so i had checked her BP for her and got in the range of 160/100, multiple times. i drove her since her hubby had to work and i was worried about her.
she went to the MD office where the CMA said "your BP is perfect!"
so the MD comes in and says, well, i don't know why you think your BP is high, and pulls out her records, and shows her the vital signs flowsheet.
ea and every time she was at the MD office... the MA had charted BP 120/80, HR 65.
so she asked the doctor to please check it himself. he got the numbers i did and put her on meds immediately and asked if she would go to walgreens to monitor her BP herself.
if you chart that you did somethat that in fact, you didn't do...
you're lying.
and while it covers the nurse's behind, it often has perilous outcomes for the pt.
leslie
I agree with this! It is lying and maybe a bit of cheating. Now it is one thing to have a check off sheet and just go wild on it, but writing a narrative note and including things that were not actually seen or you didn't actually touch...wrong. I'm sure a lawyer would have a field day with both. I've seen alot of this bad charting in my area.
I love when nice big old nurses not is written about a dressing change and includes the description of a wound....go in to do my dressing change on a bid dressing and find my intitals and wrapping from a day or even worse...2 ago. (I tape and wrap mine in my own weird way) Tell me...how was that note written if the dressing wasn't changed. Not isoalate event either. The foley that "drains yellow urine" when the pt always has amber or blood tinged urine. I can go on and on.
This does happen.
I assess even whe the pt doesn't think I am...checking the backside when they are up to the bathroom or when you turn the...yeah that stuff happens and the pt might not even know it.....but.......
I agree with all of you it is so wrong. But don't you think it is very hard to take care of 15 patient at the same time and be accurate all the time. Lower the ratio between cna's and patients . then complain if you still get poor care!
I can't believe you are justifying lying on medical records with the "I have too many patients to be accurate" excuse.
yea, I was wondering if it was one of the hospitals where they still hang the narative note on the foot of the bed. We used to do that.... the narative and check off page only. Until we found some family members writing on them!
What the heck!? WHY would a patient's family even think that that would be a good idea??
Most of the charting was that checklist style. I really found the point of checklists and "overcharting'' to be a good point! For me, I use the checklist as just that - a checklist to help me make sure that I don't forget anything I should be checking. But I do see how mundane that could get and how someone could just robotically check the boxes. The catheter care was actually written out, though
If it was written out then it was most certainly a mistake. Probably done on another person and charted on your family member. Guess what I have actually charted things in wrong chart quite a few times. That is not lying it is a mistake.
standardized computerized notes create some documentation concerns. drop-down and point-and-click charting simplifies the documentation process; however, patients are not standardized. one computerized record entry on a patient with a feeding tube, who was contracted and in fetal position, had end-stage dementia and a recent hip fracture left to heal without surgery read:
it is highly doubtful an immobile patient in fetal position and high fowler's can be log rolled and can weight shift. thirty-five degrees elevation with certainty? suture line and dressing? did this nurse do an assessment, or was the documentation entered in error? worse, several other nursing staff also had documented the wound and dressing. in most states the statute of limitations for adult patients is about 2 years. this means the nurse who documented the surgical wound and dressing will be expected to remember this patient, this documentation system and what she was thinking when this entry was made.
to document that which has not been done is considered falsification and potentially fraudulent. falsification is an intentional act. fraud is the intent to deceive. falsifications include such actions as these:
* documenting medications as given at one time when they were actually given at another time
* documenting assessments, medication administration, dressing changes, and other treatments as completed when they weren't done, or charting prior to completion
* documenting provision of care that never occurred; for example, charting care provided during a home visit that wasn't made.
also in accordance with iowa code section 147.55(3), behavior (i.e., acts, knowledge, and practices) which constitutes knowingly making misleading, deceptive, untrue, or fraudulent representations in the practice of a profession may include, but need not be limited to, the following: "falsifying records related to nursing practice or knowingly permitting the use of falsified information in those records." (iac 655 - 4.6[3]b)
falsifying the record may not just be limited to the inclusion of false information (i.e. documentation of an assessment which was never performed). under some circumstances, it is foreseeable that failure to document certain information could be construed as falsification (i.e., patient who is allergic to penicillin was given another patient's penicillin by mistake, but there is no place in the record which refers to the administration of the penicillin).
5. patients have the right to expect that the nurse/nursing assistant will always accurately report patient conditions, signs and symptoms, and the care the nurse/nursing assistant provided.
6. falsification of documents regarding patient care, incomplete or inaccurate documentation of patient care, failure to provide the care documented, or other acts of deception raise serious concerns whether the nurse/nursing assistant will continue such behavior and jeopardize the effectiveness of patient care in the future.
7. falsification of documents or deception/lying outside of the workplace, including falsification of an application for licensure or certification to the board or lying during the course of an investigation, raises concerns about the person's propensity to lie, and the likelihood that such conduct will continue in the practice of nursing.
in a court of law or appearing before the bon regarding nursing/nursing assistant documetation, doesn't matter how many patients you are carrying for on a given shift: you are held to the same standard caring for 2,6 15 05 25-30 (as in some nursing homes) patients.
when i started in 1977, i was charge lpn 11p-7:30a along with 2 nursing assistants on 26 bed unit -no other nurse. that 1 hr overtime at end of shift often was due to changes that occured in last requiring documentation after report given. as patient acuity increased, moved in 1979 to 14 bed resp/telemetry unit to decrease legal responsibility for so many patients --still the sole charge lpn, later rn. in 1982, 2 rn/lpn needed due to acuity on nights ---when i left in 1993 unit had 3-4 rn's on nights as 1/2 patients were vent dependent.
i worked per diem homecare and occasionally agency did temp staffing for snf's. when i went on one 3-11 assignment, found i was responsible for 52 patients as other nurse did not show up "the're easy ambulatory patients"---first and only time i worked that facility as placed on my do not go back list.
i completely agree that if you are not charting accurately- that is a lie and also against laws, policy and licensing rules. i am a new rn- wet behind the ears- literally one day into patient care orientation. the experienced nurse training me often made me stand there waiting for her to finish some gossip conversation with other nurses or residents. while the patient waited for pain meds or whatever. what can i do? here's the point--- is it possible that rn's are tired, and devote less energy to the patient and too much time socializing to get the work done properly? i am not trying to step on toes, but that was my one day experience, so could this be a trend?
leslie :-D
11,191 Posts
why is lying so harsh?
it IS lying...
falsifying records.
if you chart that you did somethat that in fact, you didn't do...
you're lying.
and while it covers the nurse's behind, it often has perilous outcomes for the pt.
leslie