does anyone out there copy charts to save time?

Nurses General Nursing

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Help! in in trouble with my DON. Im an RN and to save time I copied some nursing notes and used the same note on 15 sleeping patients. I work the night shift and am required to write a nursing note on every patient(15 of them) which basically says the same thing pt slept all night, no problems, still breathing etc. we always write the same note over and over so I decided to get some paper, feed it into the copy machine and hit print. then I signed and dated the 15 notes 15 times. Saved tons of time but the Don is turning me over to the SC board of nusing for disciplinary action. I know it wasnt wrong to do but now I have to provide proof that what I did wasnt wrong. does anyone know articles or laws to defend myself just trying to move into the 21st century?? thanks. Lorg gregory

Specializes in ER, Trauma.

As long as you really did all the patient checks I don't see the problem. You didn't falsify anything. Unless the note itself is inadequate (subjective as it may be) all you did was free yourself from some repetitive charting time so you could spend more time doing patient care!

Specializes in PICU, ICU, Hospice, Mgmt, DON.
Are you nuts? Of course it was wrong! You have to have original notes in charts, not photocopies. Good luck luck defending that bone headed move. I don't think you have a leg to stand on. If I were you I'd hang my head in shame, beg forgivness, say 100 Hail Mary's, and promise to never, ever, ever do it again.

THis is the CRUX of the whole matter...of course you have to have original notes in the charts. I think this was a pretty serious matter. Are you seriously saying that the assessment on every single patient was exactly exactly the same???

All of the respirations were even and unlabored? All of there sats were the same? They were all comfortable, no one required any inteventions? Etc, Etc.

Sorry, this was wrong~!

Gosh, I would have never thought to do that. I can see how it might seem like a real time saver, but...

Specializes in Current: Nursing Informatics Past:ICU.

I think your best defense would be what one of the posters said about electronic documentation. Documentation systems are setup to pull information foward to save time. Seems that is what you did.

One big question that I think you will need to stress while explainng: Did you sign each chart or did you copy your signature. If you copied your signature then I can see where it looks false. But, if you took the time to sign each one then you took the time to say I standbye what I have documented.

That was a very poor thing to do!! You know you have to have original copies. I can see how some would get fired over this. Remember a chart is a legal document and none will back you when you cut corners. Let this be a lesson to you and always follow proper polices and procedures as there is a reason why they are in place. Admit it was wrong and never do it again and maybe review what you were taught in school about charing.

THis is the CRUX of the whole matter...of course you have to have original notes in the charts. I think this was a pretty serious matter. Are you seriously saying that the assessment on every single patient was exactly exactly the same???

All of the respirations were even and unlabored? All of there sats were the same? They were all comfortable, no one required any inteventions? Etc, Etc.

Sorry, this was wrong~!

i agree - the original documentation is the real issue. however, there's also no way that 15 patients ALL slept ALL night so that alone makes things "fishy" without taking into account their respirations, sats, etc. i don't know that if it were me i would report it to the BON, but it would definitely be an issue to be addressed.

I agree with what another poster said. I understand where your coming from and can even see why you would think to do this, however, I think the problem is the copies. Like others have said you cannot have copies in the chart and even with the electronic charting your not copying one patients info and pasting it into anothers chart. My suggestion to you would be to admit you were wrong, apologize sincerely and let them know it will not happen again. It is important at this point to "own" your mistake and your actions. It is OK to make mistakes, the important think is to realize when you've made them and make the gutsy move to say "yeah, I did this and it was wrong and I am very sorry". If all goes well I would suggest changing the current documentation to something more standardized where you can check boxes off and make comments only if everything is outside the norm. Hope things work out for you, it sounds like you had good intentions just made a silly mistake.

Specializes in LTC.
Are you nuts? Of course it was wrong! You have to have original notes in charts, not photocopies. Good luck luck defending that bone headed move. I don't think you have a leg to stand on. If I were you I'd hang my head in shame, beg forgivness, say 100 Hail Mary's, and promise to never, ever, ever do it again.

How about you tell the OP what you really think.

LOL. Just kidding.

OP I believe what you did was wrong. If you can find research that justifies what you did, please let us know. WE can all learn something.

This is an interesting "turning point" His problem is that his facility paper charts. Really. The main reason most are now electronic is well, it's gonna be required - but we all know that the first facilities to totally integrate electronic charting have quickly figured out that if you HEAVILY "advise" your providers to chart in a specific way, automatically your facility comes up with "stellar" ratings. That is only until all other facilities integrate the same tricks and everybody rates as "the best" The joke is on the Joint Commission, Healthgrades, etc.

OP you are in the dog house because of the paper charting. Because it's paper it is assumed that you did not assess your patients at all. Your boss sees those copies and sees this as truth. She is also ****** that she's now got more work having to look back through your documentation in history. You gotta admit that if state saw this all HELL would break loose. You know that they don't care to try to understand. That one is a slam dunk for them. Tell me I'm wrong? Documentation is probably more important than whether or not a patient lives or dies these days. What does every NM think within the first say 5 minutes after an event? "I sure hope this is documented right!"

Specializes in pulm/cardiology pcu, surgical onc.

I'm really stumped on how you can conceivably think this was okay? Even with electronic charting I don't copy and paste the same nursing note. I've worked in facilities with both types of documentation and it really doesn't take much longer to write out a proper nursing note. If I was a nurse manager I would wonder what other corners you cut to save time?

Specializes in Gerontology.

I don't understand how you can photo copy something and then add it to a chart that already has existing nursing notes. Won't you have to cross out all the empty space left on the page before you inserted the new page? Wouldn't this interfer with the flow of the chart?

Specializes in L&D, High Risk OBGYN, Patient Education.

It appears when do this that you never assessed each patient..You will probably not be in trouble with the board other than having to explain yourself, but remember every chart is a legal document. Short cuts frequently lead to problems.

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