I am hearing about some pretty wild things going on related to nurses and documentation. So here it is, my top ten documentation disasters for the funky stuff (this is a legal term):
1. Charting ahead. Oh you know what I mean. Its only 8pm and you have charted up until 5am the next day for your 7pm-7am shift.
2. Addendums. Making addendums or changes in a medical record or on patient care documentation in violation of your facility policy.
3. Submission of false billing documentation for skilled nursing services provided and you are paid for those services. Why are you submitting notes for services you didn't provide anyway? Have you ever heard of fraud or theft?
4. Signing off documentation, charts, or flowsheets using someone else's signature. WTF, why are you intializing or signing "anything" for someone else anyway?
5. Destroying, concealing, creating, or alterating any type of medical record, flowsheet, competency, etc. after an incident to paint a prettier picture of the incident. What is your intent here?
6. Charting you peformed a task or skill on a flow sheet or in the medical record and you didn't perform the skill or task.
7. Sneaking a peek at the electronic medical records of your neighbors, family, and friends who are admitted to your hospital and you are not assigned to provide care for these individuals.
8. Getting sloppy with your administration, handling, and documentation of controlled substances in a hospital. Its your career and your license on the line. The Pharmacy Board and the police may get involved so don't be surprised.
9. Getting sloppy with your administration, handling, and documentation and counting of controlled substances in a nursing home or assisted living facility. Its your career and your license on the line. The Pharmacy Board and the police may get involved so don't be surprised.
10. The cover-up or a conspiracy (two or more nurses) to cover-up is always worse.
Have you ever heard of monkey see, monkey do?
If a nurse colleague jumped off a bridge, would you do the same just because your colleague did it?
My grandmother would say this to us all of the time growing up. LaTonia, if you saw one of your friends jump off a bridge, would you jump off the bridge? I would always so "no" of course but peer pressure is a "mother" also. Get it, now that's funny.
Trying to cover-up and conceal 1-9 and using deceit, deception, and dishonesty to rationalize your behaviors, actions or inaction when 1-9 occurs or you know that 1-9 is happening on your unit or floor and you do nothing. Remember, there is a Code of Ethics for Nurses and nursing laws and rules governing your practice.
If the funky stuff is happening on your unit, contact your State Nurses Association or a nursing law attorney in your state or jurisdiction to determine what are your reporting obligations.
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