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 had no idea that some facilities were still doing paper charting. I haven't seen paper charting in years.
I used to work at a hospital where even the ICUs had paper charting. Now I work at a facility where ICU nurses created a computer charting system thats used in all the ICUs throughout the hospital. Paper charting is still used on the general practice units. Our careplans are online also. We fill them out, print them out and place them in the chart with our signature.
I've been in a lot of hospitals, and a lot of specialties, but you can still give me a blank piece of paper over a checklist or a computer system. I know what I did and what I assessed, and what I need to write down. Most check off lists have things that are beside the point, or even irrelevant, just to cover all bases. Worse, someone goes along behind you saying, "you didn't check off x space." They are ASKING for people to fake it. I'm not saying it's OK or right. I don't think it should be remotely legal.
With checkoff lists it becomes fill in the blank nursing. When people are thinking along the lines of what they need to do for the paperwork, they miss what they can do for the patient. Patients don't fit into the lists, there is always something else, or something I need to qualify or explain. I still like narrative over any other type of charting.
I chart only what I see, what I do, and what is reported to me by CNA, LPN, or patient.
I still make mistakes, the other night I charted a very nice note, of course, it was on the wrong patient, so I errored it out, charted correctly, and went on to chart on 15 others. Sometimes the human factor takes over, if the patient was quiet, breathing, swallowed the pills, and voided, that is exactly what I chart. I may dress it up, but it is still a short note. Call me human not a lier. Please.
Barefoot, there are valid human errors in charting. I would hope no one would call you a liar. You appear very conciencious (sp?).
The only experience I had personally with something along the lines of chart fabrication was while in a Dr's office, I scanned my chart.....and there it was.... BP 120/80. Normal. Ok. I have *never* had that BP. My regular BP is around 90 - 95/58 - 60. Even PG my highest was 115/65. I did point it out to the doc and he re-took my BP and it was 90/58....*my* normal. I have no idea whether the nurse was lazy or just didn't care or wasn't paying attention, but the chart was right there as she was noting my assessment. Hmmmmm.
OMG that is so crazy. And it's makes you wounder how many mistakes and lies actually go on? That goes to show you that if at all possible to be aware of your surroundings. I had surgery not to long ago and thank God my aunts and mother were there with me,they are all nurses in fact my mom spent the night the whole time I was there. I'm speachless I'm so happy to hear your okey and I'll say a little prayer for you.
I've believe that this can happen...although OP, did you have an IV? Maybe this is what the nurse meant by catheter care? If not, that is just sad.
I agree that this is a serious matter...some things you just can't play with. Vital signs, BS, meds etc. I also agree there is no excuse. We were all taught in NS if you didn't do it, don't chart it. Simple enough to write N/A over the box if it doesn't apply to the patient..this way something is charted but it lets people know that the patient doesn't have a foley, for example.
And I think standarized checklists make you forget about what you actually assessed on your patient--makes your charting robot like. No where is there a place to demonstrate the nursing process or any critical thinking that went on.
I'm not making any attempt to address the topic of this thread, as I don't hold a job in heathcare, but maybe the rest of you can relate to this article. It's written by a doctor who has the same concerns about template-based documentation as expressed here.
"If it isn't documented, it didn't happen." It seems that more and more doctors are taking that to mean that if something IS documented, then whether or not it actually happened is moot, at least as far as payment is concerned.
What most patients don't understand is that physicians get paid on the basis of what they write down. Of course, the documentation is supposed to accurately reflect what was done, but when the auditor comes along, all that matters is the paper trail. So if a doctor spends a great deal of time with a patient performing a complex evaluation but only writes a few words, he's at risk of not being paid; whereas if he writes pages of stuff that never happened, no one bats an eye. Most of the time, no one will ever know.
Bluntly, I don't believe this story. I've never seen a nurse just happily hand over the chart to the patient without some sort of written authorization.
"Sure! Here ya go! And be sure to note any errors for your lawsuit."
I was wondering the same. Why would you hand the chart over, especially if you had been embellishing your charting!
I've been wondering about how common this, too. Last week, I was finishing my assessment on my patient (I am a student nurse) and the nurse tech came in to chart the vitals. Usually as students, we take care of this, too. I had documented everything except the respiratory rate (as I forgot to do that), and my patient was now off the floor getting xrays. The tech wrote 20 for respiratory rate, and left the room.
I thought that was pretty bold, as I know that tech not only didn't get the respiratory rate, but didn't even know for sure if the guy was breathing at all!
Then I started noticing that all of the patients seemed to have the exact same rate. Every time.
Do people routinely just put in 20 for the rate and not bother with counting?
"Do people routinely just put in 20 for the rate and not bother with counting?"
This was happening on the Neuro floor I worked on as a tech. Other techs were simply copying what the previous tech had written, instead of actually counting. I came along and had a patient one night whose respirations just looked...a lot faster than 20. More like 48. Nobody questioned when the respirations were 20 q4, but the minute I wrote down 48 and notified the RN who told me she didn't think my counting was very accurate. I told her 'ok I could be mistaken, please go count for yourself'. So she did and they were, in fact, 48. The guy coded and ended up in ICU. Who knows how long his breathing had been like that.
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BBFRN, BSN, PhD
3,779 Posts
I had no idea that some facilities were still doing paper charting. I haven't seen paper charting in years.