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6 Jan 2017 - General
 

Documentation is a crucial part of our lives as medical practicioners. It has always been an ideal practice that what has been recorded is considered as done, and what is not is considered as not done.

I have this situation just a few days back. I was the outgoing nurse and it is our practice before heading home to check our charts for its completeness. While browsing the charts, I came across this advance entry of abdominal status monitoring of the incoming nurse who are  doing their quick rounds with the patients. I was so disappointed to have seen that assessment covering his entire shift in advance without even seeing the patient. Plus knowing that the staff was a probationary is adding up injury to my mind that this is very unacceptable. 

So I waited for him to finish the quick rounds and confronted him in the medication area, just the two of us. I told him why have he done such act which is considered as dishonesty. He just starred at me blankly, with a weird, flat looking tall guy. Due to my disappointment, I have confronted him in a sarcastic way which I am not sure if its right or not. Telling, "Sir, aren't you ashamed of putting an advance entry to your patients record? Is this the right way of documenting such act?" He further reasoned out to have defended himself which have added more to my disappointment. To cut the story short, I told him not to do this again as this is a ground for sending him to make an incidental report or even worst for being expelled from the institution as we have this one consequence for dishonesty, termination. For me this is the first time I have encountered with him and being considerate enough, I guess a verbal warning is acceptable. (I may be wrong for allowing this to pass by.)

Nurses and medical practiotioners are supposed to be delivering care to their patients as honest as they can at an optimum level. We are dealing with lives and not just merely playing around.

Do you have any thoughts for this scenario or have encountered a similar situation?

(The photo was the actual recording of the document which I took right after the incident. I was thinking to bring this to our headnurse but I guess verbal warning is acceptable at the moment.)

It is also a common practice here in Pakistan where most of nurses are doing exactly like this. As told by Theekshana Abayawickrama, nurses fill their documentation and make advance entries to the patient's documents in order to finish their pape...
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I know that there is no such thing as advanced documentation. But we got to face this that this is really happening in every institution. I am also afraid for people who's committing the act of falsification of documents. Their credibility on del...
 (Total 63 words)
Theekshana Abayawickrama Thank you for sharing this dilemma. I experience something like this too. Some nurses have developed a habit of drawing a hard line on the chart 2 hours before midni...
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Well, this is not new to me. During my volunteer days at public hospital, most nurses that i have encountered did their charting ahead of time most especially during peak season (in ward setting) . As you can imagine the scenario in public hospital. ...
 (Total 102 words)
Priscilla Mae Gobuyan There is no such thing as advanced documentation. This is falsification of records and should not be treated lightly. Imagine what would happen (God forbid) if the pat...
 (Total 59 words)
Marinelle Castro Yes exactly. I don't want to generalize that person being a dishonest staff just because of one single mistake. Anyhow what can we do in small things are always possib...
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Well, what I'm about to say next might not really count as advanced documentation, but it is something that happens in my ward everyday. at the end of every day, the nurses are supposed to put the next date, write a small patient summary and allo...
 (Total 128 words)
Priscilla Mae Gobuyan It is good that you took notice about the behavior of your co-staff because advanced documentation is not acceptable. Paperworks can be really exhausting to do, but i...
 (Total 79 words)