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- by mom4josh Nov 1, '11Grrr... 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 found a note in the computer from our social worker... exact wording as my note. It's so blatantly not hers, because she does not use capitalization or correct punctuation (and I do), and I almost always write pretty much the same blurb unless there is a problem or something out of the ordinary. It's just a short three-line note. But I am furious! It's the principle of it.
I need advice. Should I confront her? Should I let it go? Anyone have anything like this happen? Thanks for the suggestions.
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- Nov 1, '11 by SparrowhawkAsk her about it...maybe it was a mistake. *doubt it* but you never know
- Nov 1, '11 by 46oldnewrnIf I am grasping for things to write on a patient that has to be documented on every single day that has been in LTC for months, heck yes I look back in old charting to see if I could pull something out so I am not so redundant. You should be flattered not angry.
- Nov 1, '11 by hoopschickSome EHR's actually use smart sets that are identical, except for very specific patient info, and share system wide or within units/specialty arenas.
It can save time, and it can assist with charting by cueing people to write the required info, and not get too wordy, which may lead to no one actually ever reading the note because it's too long.
- Nov 1, '11 by TiffyRNI was about to post about "smart phrases". Some EMR systems have this officially and we are encouraged to share them (especially those nurses that compose particularly coherent and professional sounding documentation).
I agree with the others that this is perfectly acceptable. The only thing I find unacceptable is if a person copies documentation without verifying that all copied is current.
I would find it a compliment if someone used my phrasing especially if this person struggles with such things as punctuation, spelling or syntax. As long as they did their own assessment and such documentation was accurate.
- Nov 1, '11 by netglowThat's cool and all, but I am positive that copy/paste is used in place of actual assessment by many.
- Nov 1, '11 by samirishIt would not bother me in the least..