Charting While Off the Clock

From The Floor

Charting While Off the Clock

The practice is illegal, irresponsible and breeds staff resentment

By Genevieve M. Clavreul, RN, Ph.D.
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It’s again become a topic of discussion over the past few months, but it’s an old conundrum that’s faced nearly every nurse at some point in his or her career. You’re taught throughout your nursing education that your work isn’t done until your paperwork is done, but some days you just run out of time during your shift or are ordered to clock out early because the hospital census is low. In such circumstances, you may find yourself wondering, “Is it legal for me to finish charting after I’ve already clocked out?”

The simple answer is, “No, and it can get you into a load of trouble!” However, as with many things in the world of nursing, the situation isn’t always so black and white.

The Risks

It’s important to draw a clear distinction here between late charting — charting done later in your shift, but while you’re still working — and charting done after you’ve clocked out for the day. Late charting isn’t unusual and most hospitals have procedures in place to handle it, usually involving noting that an entry is a “late entry” and circling the time. This can be done on either a paper chart or an electronic health record (EHR) and if handled properly meets generally accepted standards of care and can and does stand up to legal scrutiny.

Where the trouble begins is when nurses chart after the end of the shift when they’re off duty. If you chart after that point, you’re courting some very real risks:

• Malpractice liability: Most malpractice insurance, whether the hospital’s or your own policy, only covers you during authorized work hours. If there’s a complaint related to chart entries you’ve made while off duty, you may find yourself in an expensive or even career-ending legal predicament without the protection of insurance. Also, if the case ends up in court, an attorney could challenge the validity of almost anything you write in a patient’s chart while off the clock.

• HIPAA liability: When you’re off duty, you’re no longer considered your patients’ assigned nurse, which means that you no longer have the legal authority to access their medical information (at least until you next clock in). Even having a patient’s chart in your possession while you’re off the clock might be deemed a HIPAA violation.

• Labor law liability: If you’re charting after hours and not being paid for it, your employer can end up in hot water. Federal labor law requires employers to pay their nonexempt employees for all work performed even if the employer didn’t authorize the extra time. This includes time spent charting; in fact, Department of Labor Fact Sheet No. 53 (www.dol.gov/whd/regs/compliance/
whdfs53.htm) includes an example specifically dealing with after-hours charting at a residential care facility.

• Reprimand or termination: Even if your hospital doesn’t have any specific policy that says off-duty charting is a no-no (and many do), most employers have policies forbidding nonexempt employees to work unauthorized overtime. In some cases, violating those policies can even be grounds for termination.

In short, off-the-clock charting is bad news and can create problems for everyone involved, especially for the nurse.

In the Real World

At this point, I’m sure many of you are saying to yourselves, “Quoting federal law is all well and good, but in the real world, if I don’t clock out at the end of my shift — whether I’m finished charting or not — I’ll get written up or even fired!”

The sad truth is that too many nurses are placed in exactly that situation. With hospitals reducing headcount and trying to limit payroll costs, there is often a lot of pressure on nurses to finish their charting after hours. In today’s economy, many nurses feel they have no choice but to go along. Some even see it as part of their duty to their patients; as nurses, we’re accustomed to making sacrifices for the sake of others.

However, if we give into that pressure, we’re actually encouraging poor management. Shady workplace practices thrive in a “don’t ask, don’t tell” environment where people are too afraid to speak up. Once a manager realizes he or she can get away with these tactics, they quickly become the norm. Even worse, the more nurses give in, the harder it becomes for other nurses on the same team to say no.
 
Steps to Take

What can you do if you if you find yourself having to chart after your shift ends? Here are some steps you can take.

The first is to evaluate your work and ask yourself where the problem really lies. Are you charting off the clock because that’s the unwritten rule in your department or because you’re unable to manage your workload during your shift?

If it’s a time-management problem, ask for help: Your department or human resources should be able to offer additional training, tools or mentoring to help you. If the trouble is that you’re having trouble navigating the EHR system, your hospital may offer remedial classes that can alleviate much of the problem.

If the problem isn’t you, but the expectations of your supervisor or department, the next thing to do is to dig out the policy and procedures manual you received when you were hired and familiarize yourself with your hospital’s specific policies about working off the clock. Then, talk privately to the other nurses on your team and ask if they’re experiencing the same problem you are. If it’s a systemic issue, the odds are that your coworkers are in the same boat. Point out what you read in the policy manual and ask if your coworkers would be willing to back you up when you talk to management.

The next and hardest step is to take some deep breaths, find your backbone and go to your supervisor. Calmly point out that nurses charting after clocking out is against hospital policy — and is illegal. If you can, document some specific instances. Also be sure to document the meeting and any other conversations you have with your manager or administration about the issue.

If at all possible, get some of your coworkers to go with you when you meet with your supervisor and present a united front. If your hospital has a nursing advisory board, consider seeking their help, too. If you are represented by a union, you should also go to your union steward with your concerns.
    
Chain of Command

With issues like this, it’s important to involve your chain of command. In some cases, the hospital administration is part of the problem, but sometimes the director of nursing isn’t fully aware of the situation.

When I was a DON and learned that some nurses on my staff were charting off the clock, the first thing I did was investigate whether the practice was a workload problem or a personnel problem. Most workload-related problems could be resolved with organizational changes like revising patient loads, assigning additional personnel or clearing up procedural snags that made it harder for nurses to chart in a timely fashion. Personnel problems generally boiled down to a few individual nurses being unable to manage their workloads, which could be addressed through training and counseling.  Either way, once I knew the problem existed, I could do something about it.

If all else fails, your next and quite possibly final option is to file a labor complaint. Doing this can have serious repercussions, but if you’re committed to making a change for your fellow nurses, you might feel compelled to take this step. Before you do, you should strongly consider seeking the advice of an attorney or legal expert familiar with healthcare employment law. Not all labor laws apply the same way to all professions and the law makes some specific exceptions for healthcare professionals.

Taking a Stand

Many nurses are afraid to confront management about this kind of problem for fear of losing their jobs, but you need to recognize that if you’re charting (or doing other work) while off the clock, you’re already risking your job and possibly even your license. If you only do it occasionally, you might think it’s no big deal and if it’s the general practice in your department, going along with it might seem like the path of least resistance, but you ultimately have too much to lose.

If you’re a nurse manager — and this includes charge nurses, head nurses and everyone further up the ladder — you have a responsibility to cultivate an environment where off-the-clock charting doesn’t happen. That means making sure the nurses under you are properly trained and equipped to handle their workloads.

You should ensure that nurses who do have to stay past the end of their shifts to finish charting (which is sometimes unavoidable, although it shouldn’t become a habit) are properly compensated. Allowing or encouraging off-the-clock charting breeds staff resentment, invites a whole host of legal problems and debases the integrity of our profession.  

This article is from workingnurse.com.

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