Top ten reasons for being fired - Falsification of Documentation

didn't read all, in a hurry, I sign med when popped, it's on me to go ,if not taken....way I was trained.

Ok. Got that but when you say late entry because if interputation and adverse effect?

Do you have links to the other "Top Ten Reasons.." articles? Thanks!

So if I do a dressing change at 2000, but don't document it until I get time at 2300, I need to put 'late entry?' I'm just clarifying, because many times I won't document my assessments until many hours after I did them.

http://allnurses.com/member-61908/blog.htmlLink to where the other articles are

Quote from 0.adamantiteSo if I do a dressing change at 2000, but don't document it until I get time at 2300, I need to put 'late entry?' I'm just clarifying, because many times I won't document my assessments until many hours after I did them.

How should I acknowledge it? I do this about 95% of the time. We document electronically on flow sheets.

Here's a question: it's pretty damn hard to fake documentation time with electronic documentation softwares. It's so close to impossible that I've been assuming that I don't need to point out that I'm doing a late entry. Pulling up the medical record will show two things: (1) the time I documented an intervention; and (2) the time I'm saying I actually did the intervention. I assume that my intent, ie. retrospective documentation, is pretty obvious and I am not hiding anything. Have I been doing things incorrectly this whole time?

To clarify when doing your charting in the EMR regarding the normal day to day care of the patient you are looking after you should complete the documentation before the end of the shift. (remember check your facilities P&P to double check)With this being said, BDP is to document as soon as you can in your shift. Normal practice is within one hourIf there is an unusual occurance you need to use the exact times that this occurance happened when you document. If you give a medication late-you need to acknowledge that. Your hospital will have guidelines of how early or how late you can administer the patients medications, usually within the hour of the time. Some hospitals have tighter rules and it can be 30 mins either way. You will have to check.Normally nurses are not out to commit fraud-fraud tends to be a concious decision.

You are correct it is pretty damn hard to fake EMR's but it can be done and people will try. No you are not doing it incorrectly.the hospital is at risk if the patient has a bad outcome and sues. The standard is that documentation be completed within 1 hour of making an assessment or administering a treatment, unless an order calls for very frequent assessments or treatments or unless hospital policy states otherwise. If the documentation isn't timely, a plaintiff's attorney is likely to argue that the documentation isn't credible, which hurts the hospital's defense if the hospital is sued

Quote from 0.adamantiteSo if I do a dressing change at 2000, but don't document it until I get time at 2300, I need to put 'late entry?' I'm just clarifying, because many times I won't document my assessments until many hours after I did them.

Our hospital has a scan system for giving meds. First you scan the meds, then scan the patient, and hit enter so technically you have scanned that the meds have been given before the pt swallows them. So isn't that fraud? Sometimes a pt spits them out or they fall on the floor or something. So then I go back and chart that the med was damaged while being given.....Is there any other way to do this so I am not charting that I gave meds before I give them?