Copied documentation? Copied documentation? - pg.2 | allnurses

Copied documentation? - page 2

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... Read More

  1. Visit  mom4josh profile page
    0
    Thanks everyone for your responses. I guess I was having a bad day... :uhoh21:
  2. Visit  Blackcat99 profile page
    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."
  3. Visit  RainMom profile page
    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....
  4. Visit  Old.Timer profile page
    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.

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