Accurate documentation is essential for all members of a healthcare team to make informed decisions about the care of each individual patient's’ treatment plan. It ensures high quality, safe, timely and appropriate treatment for your patients. As a registered nursing professional, it is imperative to know what constitutes accurate documentation, and the consequences of not documenting properly. Charting inaccurate information or misleading information in a patient’s chart could put a them at risk and compromise their well-being. Falsification of information can also be detrimental for employers and fellow nurses.
Common examples of falsification in nursing:
Falsification of credentials, qualifications or professional experience
Falsifying degrees or certifications to obtain employment or career advancement
Using expired credentials or licenses to obtain employment without disclosing they are expired
Documentation and harting
Making entries in a chart that you know are inaccurate, such as vital signs, false entries in the MAR, (medication administration record), etc.
Backdating entries to make it appear that things were done in a timely manner.
Entering erroneous information to fit a diagnosis to admit a patient or get them care you think they need
Entering false information into a chart after the fact to protect yourself in the case of a lawsuit or unfavorable outcome
Time and Attendance
Recording false work hours such as start and end times for a shift
Clocking out or in for a colleague who was not there on time or who left early
Drug Diversion
Stealing medications from a facility and replacing the patient’s medication with another substance
Honesty and integrity are fundamental in nursing. Falsification can harm patients, damage your reputation, end your nursing career, cause fines or penalties, and possibly land you in jail.
Help prevent falsification of medical of medical records
Always chart true information, if you are unable to obtain something, do not make it up. Chart why it was unable to be obtained or don’t chart anything.
Try to chart in real time as much as possible, if unable to do so and your facility allows back charting, ensure you chart the information or event at the correct time it occurred.
Facilities should provide education and training on the importance of accurate charting and let employees know what is and what is not acceptable to chart. This will help ensure accurate patient information and appropriate patient care. Standards should be taught and reinforced on a regular basis.
EMR technology used should have features to help ensure accurate and timely charting is reflected in medical records. Audit trail and detection features should allow for monitoring of unauthorized entries and illegal access to patient records and alterations made to charts to help prevent falsification of information.
Charts should be monitored and audited on a regular basis to ensure that they are accurate and complete. Education should be provided to those who need additional assistance in ensuring they are charting correctly per their organizational guidelines.
Facilities should foster a culture where employees are encouraged to identify and report unethical behavior, concerning information or inaccurate charting within their organization. Employees should feel safe to report these things without repercussions.
Maintaining accurate and timely charts is of the utmost importance to ensure proper and safe patient care. It is imperative that you give your best in all situations to ensure you only chart information you know to be true and accurate. Your patients and your profession depend on you to supply ethical, appropriate and accurate care to each of your patients.