Supervisor Asked Me to Falsify Records

[Lorie Brown RN, MN, JD]

My supervisor approached me and said state was coming into our building and wanted me to fill in the empty spaces (holes) on the treatment administration record (TAR). I don't think I should but I don't want to get into trouble for not doing it. What should I do?

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I can appreciate your quandary. However, falsifying records is a violation of the Nurse Practice Act. If you provided the service but forgot to document on the TAR, you need to do it properly by following your facility's policies and procedures with a late entry.

Never just fill in the holes of a TAR and or document if you did not personally perform those services. I know you're concerned about your job and following the order of your supervisor but, as I always say, "You can get another job but you can't get another license."

Good luck.

[azhiker96, BSN, RN]

Depending on how hard your supervisor pushes this issue I'd also consider calling the compliance hotline or filing a Midas report. You should never be asked to document medications or treatments you did not give or perform.

[HomeBound]

This happened to me as well. I was called 8 days after a pt was d/c'd in order to put a "pain reassessment" in for a pain audit. First off, EPIC won't allow you to put late entries in after, I believe, 24 hours after a pt is discharged. Someone can correct me if I am wrong. But there is a REASON FOR THAT. For crying out loud--I can't even recall my patients from yesterday, let alone what a patient might have said on a pain reassessment for life saving TYLENOL (yes, it was tylenol) over a week ago!

This is the auditors trying to cover for themselves. It shows bad compliance, and yes, that is a nursing issue--you should do what your policy states that is required, plus a little common sense (nursing 101. treat and then assess that treatment's effectiveness) but at the end of the day, it's your manager's responsibility to make sure everyone is in compliance or they get in trouble. It makes them look bad as well.

I wrote back to my auditor RN asking, "So what would you like me to write into the EMR? I don't have any recollection of this patient, their response to the tylenol or whether or not I did it. I usually am confident that if I didn't chart it, I didn't do it. I'm like that, as you can most probably note from the usual thoroughness of my past charts. So would you like me to just make something up? If I do, can I go ahead and notate that you asked me to do it?"

I got crickets. Such a rebel, I guess. But here's the thing. If that manager, supervisor, or whomever would not go in there and change it under THEIR name, then they should not expect you do to it under YOURS. If they insist, then you should mention that you will make a Free Note that states that you were instructed by Jane Doe, Nurse Manager. That should put an end to it---but it will also rock the boat. Expect retaliation to be swift---as these types who ask you to risk your license have no compunction in getting back at you for making them look foolish.