does anyone out there copy charts to save time? - page 3
by lordgregoryrn 11,335 Views | 80 Comments
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
- 7May 28, '11 by netglowThis 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!"
- 4May 28, '11 by Up2nogood RNI'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?
- 8May 28, '11 by Pepper The CatI 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?
- 4May 28, '11 by mazyI 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.
- 3May 28, '11 by CompleteUnknownI 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??
- 3May 28, '11 by FancypantsRNLike others have said.... I don't get the why photocopying would be ok. I would feel wrong doing the action. Even if you handwrite the same note for all of your pt's.... how long does it take to write something like "pt lying in bed with eyes closed and unlabored resp. NAD noted". That would be faster than photocopying anyway and save you from even being questioned about whether or not you even looked in on your pt's all night.
- 4May 28, '11 by Altra GuideSorry OP -- the photocopied documentation makes it difficult to avoid the appearance that you did not look at 14 or 15 patients all night.
I understand the point about comparing this to an electronic copy/paste function. But appearances do matter, whether we like it or not. If anything had happened to any one of those 15 people overnight, a photocopied note might well be an insurmountable obstacle for you the RN and for your employer to demonstrate that adequate supervision, assessment and care had been provided.
- 2May 28, '11 by cherrybreezeWhat you did was very wrong, and the reasons have been pointed out by the previous posters, so I won't rehash them.
What gets me is not only did you do something so blatantly wrong and don't believe you did, THEN you ask US to find you support for your actions.
If you want to defend yourself, put the work in!!