Copied documentation?

  1. 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 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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    About mom4josh

    Joined: Mar '06; Posts: 290; Likes: 270
    Epic Application Analyst; from US
    Specialty: 11 year(s) of experience in onc, M/S, hospice, nursing informatics


  3. by   Blackcat99
    Just let it go. People do that kind of thing all the time in nursing. It's a compliment to you. They liked what you wrote so decided to use it for themselves too.
  4. by   TheCommuter
    One of my former coworkers made a copy of my generic nurses note and used it to chart on all of her patients that were having no specific issues during that shift. I had no issues with the fact that she had done this.
  5. by   Sparrowhawk
    Ask her about it...maybe it was a mistake. *doubt it* but you never know
  6. by   46oldnewrn
    If 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.
  7. by   vanburbian
    Some 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.
  8. by   TiffyRN
    I 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.
  9. by   systoly
    Take it as a compliment.
  10. by   netglow
    That's cool and all, but I am positive that copy/paste is used in place of actual assessment by many.
  11. by   samirish
    It would not bother me in the least..
  12. by   caliotter3
    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.
  13. by   MrChicagoRN
    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
  14. by   MunoRN
    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