What constitutes falsifying documentation?

[physioex]

I know of a nurse who put her initials on a flow sheet for her entire shift ahead of time. She was in orientation and was never told by preceptor or coworkers that this constituted falsification of documentation. She was terminated for doing it on 3 occasions. She never falsified assessments, v/s, outcomes, plans of care, only initialed her flowsheet for her entire shift before it was actually that time. She'd been complaining of coworkers being viscious, making false accusations, and tattle telling about non-nursing related matters. She'd had felt like she was being watched closely to get fired and now it came true!! Can she really be terminated for this? Is this really falsification if she did the actually charting at the real time, but only initialed ahead of time?

[Spritenurse1210, BSN, RN]

I'm sorry to hear about your coworker. I don't see how just putting your initials on the flow sheet constitutes falsifying documentation. I may be wrong.

[Hospice Nurse LPN, BSN, RN]

It is falsification. What if something happened and the pt died or was sent to the hosp or went on pass with family? What if the nurse had to leave her shift early? How would she explain documenting those items? I used to work with a nurse who signed her entire MAR/TAR before a.m. med pass. It's just wrong.

[Flying ICU RN]

can she really be terminated for this? is this really falsification if she did the actually charting at the real time, but only initialed ahead of time?

in a word,.. absolutely.

what may seem a minor transgression in documentation by an individual, calls into question the entire treatment record and by default, the institution's "covenant of public trust."

[pielęgniarka, RN]

Yes it is falsification, I was taught this is a big no-no. The initials signal that the task was completed. Where I work you cannot sign for anything until it is completed. MARs (med admin record) get initialed after the meds are given. TARs (treat. admin record) get initialed after the treatments are completed.

[RN1980]

its just bad form and practice to do this. the med record and tx record are there not only for other staff members to see what meds/treatments have been done and when they were completed, but it also serves you as a reminder of what was completed and what is not. just think at the end of a busy day you look at your med or tx record and you have initialed everything before hand you could have actually overlooked a med or tx but since you intialed it earlier you'll never know. this is a bad practice for all you younger nurses out there. beware....

[MsbossyRN]

I'm just surprised she wasn't told the first time she did it, that it was wrong. I am sure if she were told she was not to do it, they could have avoid firing her.

[Asystole RN]

$1,000 says that she was not terminated for what was described.

The falsifying docs was the excuse (the paper trail) used to remove her. She was either doing something else that was difficult for leadership to officially remove her for or she rubbed the wrong person the wrong way.

[roser13, ASN, RN]

"a nurse who put her initials on a flow sheet for her entire shift ahead of time"

"Ahead of time" is all that needs to be said. Anyone who signs their name to documentation that doesn't correlate to real time is asking for trouble.

No question at all.

[Batman25]

It's falsification and legitimate reasoning for a firing. Huge liability.

[Scarlette Wings]

she was in orientation and was never told by preceptor or coworkers that this constituted falsification of documentation.

please take this with all due respect but back up and think about the situation objectively just a minute. there are probably 10 billion things that no one specifically tells us while we are in orientation,school, or while training for a new job but that should be basic common sense

.

no one specifically tells us:

1. do not steal,

2. do not lie,

3. do not divert drugs,

4. do not misappropriate money, meds, dentures, or anything else a patient gives us to lock up,

5. do not pick our nose,

6. do not scratch out in public,

7. do not run from a code no matter how scared you are ..... etc

why should anyone really have to "tell" another adult to not sign anything before it is done?

patients wander off, go off the unit for procedures, crash and get transferred into icu, not to mention code.

if you initial something because it is "just easier to do it this way" and not because it is right, then how do i know they have "done" the wound care or whatever that is charted?

most schools drill into your brain and to the backs of your eyelids

1. if it isn't charted, it wasn't done. and

2. document it as soon as you can and as close to the time it was done after you finish _____. (insert task skill intervention here.)

[gymnut]

It is falsification. What if something happened and the pt died or was sent to the hosp or went on pass with family? What if the nurse had to leave her shift early? How would she explain documenting those items? I used to work with a nurse who signed her entire MAR/TAR before a.m. med pass. It's just wrong.

I agree completely with this. It is pure falsification of documentation and while I have never worked in the health care field I have worked in a pharmaceutical packaging plant were many people were fired for doing exactly that.

An example of this was when one QA would do exactly what your co-worker did and sign off that all her checks and tests were completed for the entire shift at the beginning of the shift. One day she came on a line where we were packaging something for a high end drug manufacturer and signed everything off as usual. Needless to say the line broke down right in the middle of the shift around 7pm and we couldn't get it running again. The facilitator came out and noticed her documentation and asked how she could have done it all the way to 11pm if the line broke at 7? She was fired on the spot.

In my honest opinion it's just being lazy to me. It's your initials not a biography on the patient so just take the 2 lousy seconds to jot them down.