World Nursing Congress 2019 | 53rd World Congress on Nursing and Healthcare

Avoid untruths in your nursing documentation

A reader submitted a question about nurse managers in a home health agency documenting the start and stop times for IV infusions. The nurse managers did not administer the IVs. The reason this practice occurred was so the nurse managers could be paid for the infusions.

A long-standing, essential principle of nursing documentation is that it be truthful and accurate. Moreover, you as a nurse are responsible for your own documentation. If you document for another, you must alert the reader of that fact by indicating you are doing so for the identified nurse (by name) and then signing your name after the notation.

If these legal and ethical standards are not met, the documentation that takes place is considered false, untrue, misleading and deceitful.

Backdated documentation is cause for concern

How much of a delay occurs due to this practice is one concern. The other is how the nurse manager is indicating the start and stop dates in the record.

Are the entries backdated? In other words, if an IV was stopped on Wednesday, Jan. 12, is the entry dated as such even though the documentation took place on Jan. 16, or is it entered on the day the nurse manager actually documents the stop date, indicating it as a “late entry” or as an “addition to the notation” pursuant to the agency’s documentation policies?

Another instance of legal inaccuracy is if the nurse manager backdates the notation. If, on the other hand, the nurse manager dates the start and stop dates truthfully but indicates the actual date of the entry as well, that is legally acceptable.

It may not be acceptable, however, for the insurance company who is paying for those IVs, whether its Medicare, Medicaid or a private insurance company.

As a result, not only is the nurse manager falsifying the record, the practice may result in a non-payment by the insurance company for the IV because it was not documented timely.

Payments also can be problematic

One last legal problem raised by the reader’s question is that the nurse managers were falsely documenting so they could be paid for the infusion.

Does this statement mean the nurse managers personally were being paid as a result of their visit and documentation? Or does it mean the agency was being paid for the visit? Unclear, to be sure, but still troubling.

It is important that as a nurse license you never falsify nursing documentation or any document in relation to your nursing practice.

Your inability to practice nursing with an unencumbered license is but one ramification if you do so. Another consequence is that your veracity will be severely compromised, a result that will follow you for the rest of your professional life.

World Nursing Congress 2019

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