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

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.

Specializes in Plastics. General Surgery. ITU. Oncology.

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

My goodness! What a lot of self-rightoeous hypocrites you all are.

What exactly are we being hypocritical about?

Specializes in Telemetry.
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?

Specializes in PICU, ICU, Hospice, Mgmt, DON.
my goodness! what a lot of self-rightoeoushypocrites you all are. really???? because we gave our opinions with information to back it up....we are hypocrites? i think not!

copying some notes? big deal. who cares as long as the patients were ok.

actually it is a big deal

as the nurse in charge of my ward (which i am) i'd have taken no notice of this. that is very sad

all the patients were fine. duplicated note? get a life

well, let's examine this......

i see that you do not live in the usa so you are probably not in tune to the legal ramifications of this....but can you spell litigation?...unfortunately here in america we have to watch out for every little detail. this country is law suit oriented and one little thing could spark a big issue. even if this did not lead to anything, it still appears as if this nurse never laid eyes on these patients all shift.

that would be the case i would bet any defense counsel would make..and win--had any little thing gone wrong with any one of those patients," well how do you know your pt was breathing at midnight, you photocopied those notes for everone???." as said in court.

the nurse manager is aware of this fact and that is why she/he is so upset. frankly, i am surprised this nurse did not lose this job. plus, i am pretty sure it is a blatent violation of the hospital policy. i think you could search all day , no where would you find that it is ok to photocopy notes and sign them.

sorry, i can't get around this one.

the diva.....who is not a hypocrite and who has never photocopied notes!

Specializes in Plastics. General Surgery. ITU. Oncology.

What a lot of nonsense. No fortunately I'm English and this rubbish is not yet a nursing requirement. We are still more interested in the patient than in the paperwork.

BIG DEAL if nothing at all is written overnight let alone a lot of identical nothing if bugger all has in fact happened.

I'd never pull a nurse up on it.

Specializes in Gerontology.
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

Because to me if someone is going to take short cuts with charting, then the risk is there that they are taking short cuts in other places. Yes, the pts were fine. But that is not the point. this is sloppy nursing and pure laziness. I would not want to work with someone who thinks short cuts like this are OK

Specializes in Plastics. General Surgery. ITU. Oncology.

Totally disagree. If there is nothing to be charted then there is nothing to be charted.

Dosen't mean the nurse is lazy or irresponsible at all.

Ans surely the whole POINT is that the patients were fine. Isn't that what we are all there for?

I've worked with nurses who take "shortcuts" in signing off on meds that I know they didn't give, (i.e. never ordered from pharmacy, ABX not in e-kit, narcotic count off) or gave late, or gave too much of. Or they sign off that they did treatments and when I follow up I find my own signature and date on the dressings from the last time I worked with the patient three days earlier -- so however many shifts of following nurses didn't even look at the patient.

It is a whole lot easier to get away with "shortcuts" like this with paper charting than with electronic charting because it is human beings who are monitoring the charts and humans are not nearly as reliable as computers when it comes to the cold hard math.

I've worked in facilities that are so anal about charting that if you put down your pen in the middle of a note and pick up another one to finish it they will make you come back in and write a correction. Pretty crazy and frustrating. A facility can lose it's Medicare certification for charting mistakes, because State assumes that a facility that cannot stay on top of holes in charts is probably not on top of what it's staff is doing.

I think that the reason that the OP is looking at a conversation with the BON is that the DON knows how serious something like that would be if State came through and she has to show that she made a serious gesture in terms of correcting the problem. Whether it amounts to anything is another story. The point is that a complaint has been filed against the OP with the BON and that's pretty hard to shake off.

Yeah, litigation is a huge issue, but I think the bigger issue is that as a person in a position of trust over vulnerable individuals, the OP needs to actually make the time and effort to do the job well, even if that means charting the same thing over and over, which shouldn't be happening anyway with 15 patients.

Also, I think the OP is gone so so it's all moot.

I still don't understand what we're being hypocritical about. Or does that word mean something else in England?

Specializes in Mental Health, Medical Research, Periop.
Totally disagree. If there is nothing to be charted then there is nothing to be charted.

Dosen't mean the nurse is lazy or irresponsible at all.

Ans surely the whole POINT is that the patients were fine. Isn't that what we are all there for?

Doesn't work like that in the U.S.A. There is always something to be charted. Documentation is vital here. You're looking at it from a UK point of view which is actually not helpful to the OP at all (unless he is in the UK). So know this, if you move to the US you have to change your train of thought or you will find yourself in a world of trouble, just like the OP. IMO.

Specializes in PICU, ICU, Hospice, Mgmt, DON.

[color=#333333]this is for hiddencat...

[color=#333333]

[color=#333333]hmmmmmm.....

[color=#333333]this is from websters...so i think its sort of universal.

[color=#333333]hypocrite:

1.a person who pretends to have virtues, moral or religious beliefs, principles, etc., that he or she does not actually possess, especially a person whose actions belie stated beliefs

[color=#333333]2. a person who feigns some desirable or publicly approved attitude, especially one whose private life, opinions, or statements belie his or her public statements.

not sure if that "clears it up" but i tried..:)

diva (still not a hypocrite)

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