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

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... Read More

  1. Visit  diva rn profile page
    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.
  2. Get the hottest topics every week!

    Subscribe to our free Nursing Insights newsletter.

  3. Visit  Anna Flaxis profile page
    0
    Gosh, I would have never thought to do that. I can see how it might seem like a real time saver, but...
  4. Visit  Matthew_RN profile page
    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.
  5. Visit  Sherriblu profile page
    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.
  6. Visit  JSlovex2 profile page
    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.
  7. Visit  FunRun profile page
    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.
  8. Visit  NurseLoveJoy88 profile page
    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.
  9. Visit  netglow profile page
    7
    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!"
    Batman25, nicole1207, noyesno, and 4 others like this.
  10. Visit  Up2nogood RN profile page
    4
    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?
    Batman25, diva rn, Not_A_Hat_Person, and 1 other like this.
  11. Visit  Pepper The Cat profile page
    8
    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?
    Batman25, DizzyLizzyNurse, mesa1979, and 5 others like this.
  12. Visit  radioactivern profile page
    0
    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.
  13. Visit  mazy profile page
    4
    I can't imagine how you would think this is OK for paper charting. You need a separate note for each patient with their unique information, even if you are charting by hand you still need specific information for specific patients.

    As Pepper the Cat pointed out, you can't just randomly stick notes in a chart without taking into account the flow of documentation. As other posters pointed out, if you are taking shortcuts with charting you are probably taking shortcuts with nursing and I think your DON has a right to be concerned -- how can they know that you have actually assessed the patient?

    You made a big mistake. I think that rather than trying to figure out how to justify your actions, maybe you should do an assessment of why you were wrong and then talk to your DON, apologize profusely, and pray that you don't lose your job.
    RNKel, Batman25, Mrs. SnowStormRN, and 1 other like this.
  14. Visit  CompleteUnknown profile page
    3
    I can't imagine how it could be okay to photocopy a nurse's note 15 times, sign each one, and then place one in each chart. I'm also really puzzled that the OP thinks it is okay for each patient to have the exact same entry in their chart for the shift, even if not photocopied. Am I missing something??


Nursing Jobs in every specialty and state. Visit today and find your dream job.

Top