does anyone out there copy charts to save time? - page 4

by lordgregoryrn 11,329 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


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    Not only was it wrong, but IMO, even if every single patient has the same assessment (which is highly unlikely), I think it's a good idea to find something unique to write about each pt. It shows that you really truly DID assess them.

    People mentioned EMR - at one hospital network I worked for, they disabled the 'C&P' function so that you couldn't do that from a previous nurse's note. That was for the SAME patient. I don't even think it occurred to them that a nurse would actually try to do that for DIFFERENT patients. It boggles the mind.
  2. 0
    Quote from Altra
    Sorry 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.
    The OPs post brought to mind a mental picture of him sitting at the nurses' station almost all of the shift, nodding off, or on the internet. Imagine discussing this charting practice on a witness stand!
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    My facility has disabled the "copy and paste" function on charting so that we cannot copy and paste the same note, even for the same patient. When I chart, I write something personal about each patient, even if everything was fine for the entire shift, no c/o pain, etc. Even just an observation that the patient had visitors shows you were paying attention. And, since I used to work nights, I know that even sleeping patients have to use the commode/bathroom, etc. at least once during the night.
    Mrs. SnowStormRN likes this.
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    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.
    Are you kidding?

    First of all, it gives the appearance (whether accurate or not) that the OP didn't bother to assess the patients at all. Good luck defending that if a case goes to ligitation. What if one of those patients died while strangling in their bed rails in their sleep (or some other accident) and the home was sued for negligence? And an investigator discovered the copied notes and dug further and found the same exact copied note on multiple patients for the night in question?

    Electronic charting actually does keep a record. If you chart something, and then go back and change it, it doesn't show on YOUR printed record but that activity IS stored in the system and can be retrieved if necessary. I work very closely with our IS department and our EMR vendor - I know that this is true. If there is a court case, attorneys can subpeona the full record, which will show any changes made to documentation including what time or date the alterations were made. Just because YOU can't see them doesn't mean they aren't there.

    On all the electronic charting systems I've worked in, you can't copy info from one patient into another's chart without making an awfully huge effort - like writing it out in MSWord and then doing a copy and paste function. In our EMR, you can't even paste something you've copied from somewhere else, but you can copy your own previous charting so that you can just update what really has changed. And even THAT will come into question if there's an incident and your charting didn't change over the entire night or day.

    Falsification is not limited to altering documents, as you seem to be implying. It also encompasses documenting untruths. Frankly, if the OP is writing the exact same note on every patient every night, there's probably more falsification than just copying notes going on. I would seriously have my doubts as the manager of this facility that the patients were being assessed at all by this person.
    Batman25, Altra, Mrs. SnowStormRN, and 1 other like this.
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    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.
    False charting is the problem. It is not true that "all" charting has to be original notes and no photocopies.

    Our charts are FULL of photocopies. We make photocopies of our flushing protocol where the Neo simply checks off which one he wants to use and the nurse signs off on it. We do that with central lines as well among other things.

    The OP did not false chart...she only copied verbatim, what she would have otherwise charted...if she SIGNS OFF an original signature and current date, she is agreeing that what is WRITTEN is what happened, copied or not.

    They would have to prove otherwise, in order to turn her in.

    I have a sneaking suspicion that this is something that everyone THINKS is wrong, while not the recommended way to go..is probably going to be ok in the end. I don't think the BON will even care.
    morte and wooh like this.
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    Quote from JulieCVICURN
    Are you kidding?

    First of all, it gives the appearance (whether accurate or not) that the OP didn't bother to assess the patients at all. Good luck defending that if a case goes to ligitation. What if one of those patients died while strangling in their bed rails in their sleep (or some other accident) and the home was sued for negligence? And an investigator discovered the copied notes and dug further and found the same exact copied note on multiple patients for the night in question?.
    But that is not what happened on HER shift. When the OP signed off they were A-Ok.

    An original note doesn't = assessment. As if an RN cannot write she assessed and then really didn't.
    morte and wooh like this.
  7. 0
    Quote from klone
    Not only was it wrong, but IMO, even if every single patient has the same assessment (which is highly unlikely), I think it's a good idea to find something unique to write about each pt. It shows that you really truly DID assess them.

    People mentioned EMR - at one hospital network I worked for, they disabled the 'C&P' function so that you couldn't do that from a previous nurse's note. That was for the SAME patient. I don't even think it occurred to them that a nurse would actually try to do that for DIFFERENT patients. It boggles the mind.
    I have electronic charting and I NEVER use copy and paste, within the same chart or without.

    I actually cringed when I read the OP.
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    My goodness! What a lot of self-rightoeous hypocrites you all are.

    Copying some notes? Big deal. Who cares as long as the patients were OK.

    As the nurse in charge of my ward (which I am) I'd have taken no notice of this.

    All the patients were fine. Duplicated note? GET A LIFE
    morte and wooh like this.
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    Quote from iNurseUK
    My goodness! What a lot of self-rightoeous hypocrites you all are.
    What exactly are we being hypocritical about?
    Mrs. SnowStormRN likes this.
  10. 1
    Quote from iNurseUK
    My goodness! What a lot of self-rightoeous hypocrites you all are.

    Copying some notes? Big deal. Who cares as long as the patients were OK.

    As the nurse in charge of my ward (which I am) I'd have taken no notice of this.

    All the patients were fine. Duplicated note? GET A LIFE
    No 15 patients are EVER the same. What kind of nurses note could possibly be applied to ALL 15 patients? It would never occur to me to photo copy a nurses note....is that even allowed?
    Mrs. SnowStormRN likes this.


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