Copied documentation? - page 2

by mom4josh 2,798 Views | 16 Comments

Grrr... so frustrated! I work with a social worker, and part of our job is to do initial consultations with potential hospice patients. I was checking some charting yesterday on a patient when we did a visit together, and I... Read More


  1. 1
    Quote from netglow
    That's cool and all, but I am positive that copy/paste is used in place of actual assessment by many.
    This would be my concern. But not really my worry, as it is she who would have to justify her actions.
    GrnTea likes this.
  2. 0
    I'd wonder if she's actually doing an assessment.

    Personalize the charting a bit to include proper names "lives with husband Sam," or "Mrs Jones agreed to..."


    Then see if those entries are unread cut and paste jobs
  3. 0
    It's pretty standard for Social Workers to refer to the Nursing Assessment and Plan, using your written assessment and plan in the SW note is one reason why you chart it; for others to use in the care and planning for the patient. This can either be done by re-phrasing your charting and potentially misinterpreting it, or copy and paste which is the most accurate option. You don't own the charting you do on a patient, the patient does, the best plan is probably to get over it and be glad that someone found a Nurse's note useful.
    Last edit by MunoRN on Nov 2, '11
  4. 0
    Thanks everyone for your responses. I guess I was having a bad day... :uhoh21:
  5. 0
    Quote from mom4josh
    Thanks everyone for your responses. I guess I was having a bad day... :uhoh21:
    Not a problem. I know how I felt when it happened to me for the very first time. I was absolutely furious.
    I thought "How dare they steal my charting."
  6. 0
    Quote from netglow
    That's cool and all, but I am positive that copy/paste is used in place of actual assessment by many.
    I've started to wonder about this on my floor. Being a new grad, I'm not always confident about what I'm finding on a pt, usually breath sounds, sometimes the degree of edema or pulse strength. Our system allows the recall of values so you can automatically complete the section with what was charted previously so sometimes I look to see if the last RN was hearing the crackles I think I'm hearing (although obviously it could be a new development from the last assessment). However, I found on one of my pts a couple nights ago, that it really seems like people are blowing thru their assessment & possibly just recharting the same previous findings of others. This elderly gentleman, 84, (like most) did NOT have GOOD or even fair turgor (expected), had skin breakdown, was on fluid restriction w/renal issues/foley/low output (therefore pretty sure voiding cannot be charted "w/no difficulty".) However, over and over (even by the more seasoned day shift nurses), skin was clean/dry/intact w/ good turgor, no voiding difficulty, lungs clear (though I thought diminished & charted it.) This was also a pt who it was thought was having diarrhea, given immodium regularly for the past few shifts, when it was actually an impaction that was taken care of (thank goodness! lol) just before my shift started.

    Just makes me wonder....
  7. 0
    Quote from netglow
    that's cool and all, but i am positive that copy/paste is used in place of actual assessment by many.

    Quote from nu rn
    i've started to wonder about this on my floor. being a new grad, i'm not always confident about what i'm finding on a pt, usually breath sounds, sometimes the degree of edema or pulse strength. our system allows the recall of values so you can automatically complete the section with what was charted previously so sometimes i look to see if the last rn was hearing the crackles i think i'm hearing (although obviously it could be a new development from the last assessment). however, i found on one of my pts a couple nights ago, that it really seems like people are blowing thru their assessment & possibly just recharting the same previous findings of others. this elderly gentleman, 84, (like most) did not have good or even fair turgor (expected), had skin breakdown, was on fluid restriction w/renal issues/foley/low output (therefore pretty sure voiding cannot be charted "w/no difficulty".) however, over and over (even by the more seasoned day shift nurses), skin was clean/dry/intact w/ good turgor, no voiding difficulty, lungs clear (though i thought diminished & charted it.) this was also a pt who it was thought was having diarrhea, given immodium regularly for the past few shifts, when it was actually an impaction that was taken care of (thank goodness! lol) just before my shift started.

    just makes me wonder....

    social work copying initial nursing assessment for hospice admission is one thing, but......

    identical detailed nursing assessment "notes" (vs electronically populating a field with set responses) for a patient that are completed on sequential shifts should raise a red flag on those assessments.....so no, that would not flatter me.

    the reality of what nu rn describes happening should set off alarm bells for anyone who considers patient advocacy part of their role. good for you nu rn for noticing and caring.


Top