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Nurse Is Concerned PCTs Are Not Documenting Properly on Patient Charts


An RN submitted a question about her patient care technicians not signing off on their work and sometimes not taking patients' vital signs.

Repeated reporting of these omissions to her supervisor resulted in no change. In fact, the RN stated she had been written up for complaining to the PCTs. In addition, since she states she is unable to "close shifts" at the end of the day, she also was written up for not doing so. Her supervisor told her to document the information and sign the PCTs' names to any labs, meds or care. The reader asked if this constitutes falsifying documentation. The simple answer is, "Yes." Any time you sign another person's name on a patient record with the intent to deceive another person or entity, falsification occurs. It is seen as a felony under criminal law and is especially a concern when the person doing so falsifies a legal record to obtain financial gain. The reader said her supervisor told her not closing the shift results in the healthcare entity's parent company losing money.

In addition to the potential for criminal liability, the nurse also can face disciplinary action by the state board of nursing. Most nurse practice acts list falsification of a patient record or document required by his or her nursing practice (e.g., time cards) as a basis for professional discipline. Last, but by no means least, any falsification involved within your nursing practice is unethical.

What can you do to protect yourself?

Rather than handle the PCTs' refusal to fulfill their job responsibilities as the supervisor suggests, the nurse does have several options, and they all rest on principles of good supervision of delegated patient care and good documentation. The PCTs are supervised by the RN. Their care is delegated by her and they are required to report to her concerning the care that she has delegated. So, at least verbally, she should regularly receive information about patients' statuses. For example, the RN might document: "Mary L, PCT, reported to me [or this RN] at 2:30 p.m. that patient John Jones' blood pressure readings were 150/80 at 8:30 a.m. and 135/80 at 2 p.m. - Nurse Smith, RN." The reader did not include how the PCTs "sign off" their work, but it is assumed if they do not document directly in the patient record that they document their findings on "worksheets," which may or may not become part of a patient's record. Assuming the PCTs are not signing off on these documents, the RN can use them by including the information in her notes: "Reviewed Vitals Sheet for John Jones at 2:40 p.m. on 1/2/18. All vitals within normal limits. - Nurse Smith, RN." If "worksheets" are to be part of the record, the RN can make a notation on the worksheet that she reviewed it and time and date that notation. The notation could look like this: "Reviewed Vitals Sheet. - Nurse Smith, RN. 1/2/18 at 2:40 p.m." Any follow up or concerns about the information on the Vitals Sheet would need to be addressed in Nurse Smith's documentation for that patient.

This does make extra work for the RN, but she is not violating any of her legal or ethical responsibilities with it. Rather, she is fulfilling her responsibilities as the charge nurse in the situation.

In addition, the RN in this situation should be reporting the PCTs' conduct to an agency that regulates them, if one exists, or to the educational program from which they graduated. If the supervisor is not going to enforce the PCTs' obligations in the position they hold, then reporting them to an organization outside of the workplace is important. The nurse who asked the original question also might consider confidentially reporting her supervisor to the state board of nursing. The supervisor is violating his or her own ethical and legal responsibilities as a licensed RN under the state nurse practice act and regulations. It does not appear that the RN would have any legal recourse with the Equal Employment Opportunity Commission for stress and retaliation. Nor would a Workers' Compensation claim be appropriate. The legal argument against her claims would most likely be that it is her responsibility to ensure proper and adequate documentation in the patient record and options are available to her to ensure the information obtained by the PCTs gets into the patients' records. Grieving the write-ups by her supervisor would be worth a try, but it does not seem the supervisor's attention is on anything other than ensuring the company does not lose money. The only realistic option for the RN reader may be to simply look for a new position with another employer. Did you go through something similar? If so, how did you resolve the situation?  

Check out these courses related to delegation and proper charting:

Delegating to Unlicensed Assistive Personnel (1 contact hr) The skill and art of delegation for effective use of unlicensed assistive personnel (UAP) is a critical 21st century nursing competency identified by the American Nurses Association and National Council of State Boards of Nursing, yet many nurses remain uncomfortable with delegation. This educational activity will address the role of delegation in providing quality care in a collaborative environment and will provide strategies for effective delegation. Document It Right: Would Your Charting Stand Up to Scrutiny? (1 contact hr) This module provides nurses with information about the value of laws and standards governing nursing documentation, legal basics for appropriate documentation, and strategies for documenting changes in a patient's condition. It describes the legal definition of nursing negligence, characteristics of legally credible charting, and charting practices that can lead to legal problems. Healthcare Fraud (1 contact hr) Healthcare fraud continues to drain billions of dollars from the U.S. healthcare system annually and depletes the system of valuable and limited resources. Healthcare professionals, as patient advocates, are in a unique position to support patients in obtaining and keeping the healthcare services they need by helping to combat fraud. Nearly every healthcare service type has been involved, or has the potential to be involved, in fraudulent activity that healthcare professionals can help eliminate. Often, they have access to information that enables them to identify fraud long before investigators or law enforcement officers do. As advocates, healthcare professionals can help patients to recognize and report fraud, and help employers avoid fraud.