does anyone out there copy charts to save time? - page 2

by lordgregoryrn

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)... Read More


  1. 0
    Quote from JulieCVICURN
    But it WAS wrong. Maybe you would have written the same thing on every patient, but what you did makes the documentation look as if it's been falsified. If I were a Joint Commission surveyor, I'd have been all over your facility if I found some glaring evidence of negligent charting like that.
    So what would have appeared to be falsified?

    I would guess that HAND written charting would be easier to falsify than copies that are signed. If you really wanted to falsify something, all you have to do is toss the original, get a new sheet and fill in what you need. Original handwriting is very detectable.

    You can't do that with a copy.

    The purpose of charting is accurate information...as long as the patient identifier is there, the information is accurate and bears an original signature, it should be rendered as valid.

    Electronic charting is no different...the same thing appears on the screen over and over again and I can go back and change any of it I want...what we PRINT is in the chart..our printed copies DO NOT show that I made ANY corrections.
  2. 10
    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.
    Batman25, joanna73, LadyinScrubs, and 7 others like this.
  3. 1
    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!
    wooh likes this.
  4. 7
    Quote from linearthinker
    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~!
    Batman25, joanna73, melmarie23, and 4 others like this.
  5. 0
    Gosh, I would have never thought to do that. I can see how it might seem like a real time saver, but...
  6. 1
    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.
    wooh likes this.
  7. 3
    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.
  8. 3
    Quote from diva rn
    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.
  9. 1
    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.
    RNKel likes this.
  10. 0
    Quote from linearthinker
    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.


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