does anyone out there copy charts to save time? - page 6

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  tikilpn2 profile page
    2
    You doing that can cause your administrators to feel like you were not looking in on your patients and assuming that their status was unchanged or stable which can be very dangerous..:uhoh21:
  2. Visit  carolmaccas66 profile page
    2
    Illegal in Australia. All notes must be written and signed, dated, with your title etc on the day in the next entry in the medical record.
    You can't go against written hospital and nursing policy anyway, so I don't see how you thought this would save you time, really. Now it's going to take MORE time to try and justify yourself.
    Writing notes can be a bore, but it's part of the job unfortunately.
    Mrs. SnowStormRN and Batman25 like this.
  3. Visit  carolmaccas66 profile page
    0
    I meant to add as well: who the hell has time to photocopy stuff anyway? I'm too busy running around actually assessing and helping patients!
  4. Visit  BabyLady profile page
    3
    Quote from juliecvicurn
    if i'm an attorney, or even a unit manager, i'm asking, "are you sure? because when i look back in the charts all i see are copies of the same handwritten note that's on all the patients. did you really assess them? because it looks to me like you copied one note and then facebooked all night."
    we are not discussing if her facility charts by exception or not...obviously not or else she would not have felt it necessary to write the note. i would confidently answer an attorney: when i signed off on the notes, i am making a legal statement that what was written, original or not, above my name is an event that is true and that occurred. nurses are fully capable of false charting by original handwriting.

    just because it is a copy, doesn't make it any more false than original handwriting makes it any more true.

    if i sign it, i stand by what i signed off on.

    Quote from juliecvicurn
    my point to the op has been that the appearance of negligence or impropriety is just as important as whether or not the impropriety actually occurred.
    no...negligence has to be proven. it cannot be suggested, it has to be proven in a court. if the op's charting occurred on may 15th and something happened to the patient on may 16th, and the op didn't work on may 16th? then you need to take a look at whoever did the first assessment on those patients on may 16th...if she charted at the start of her shift that the patients were fine and the something happened later, then you don't need to be pointing the finger at the nurse on may 15th.

    Quote from juliecvicurn
    you don't want to do anything that is difficult to defend in a lawsuit. your actions make it look like you didn't assess your patients, even if you did. i can't comment on your work ethic - you may be the best nurse in the facility. but what you did made you look otherwise.
    what part makes it look like she did not assess her patients? again, you are assuming that no nurse has ever false charted before...happens all the time if you look at your bon disciplinary actions. that is like saying that when pre-printed standardized orders are printed off and signed off on by the physician, that it looks like he never treated the patient or reviewed the orders. funny how nobody ever says that...they say that "if he signs off on it, that is what we follow".

    same exact thing with the op...she signed an original signature. that is all that matters.
    Tampabay-b, punkydoodlesRN, and wooh like this.
  5. Visit  lordgregoryrn profile page
    0
    thank you Julie
    you gave the best answer. my don just doesnt know me cuz if she did she wouldnt have acused me without evidence.
    ive been to court dozens of times over non nursing issues and 1st off no other charts will be allowed into evidence only the one suing and that one would have to prove something happened not that something didnt happen- because I charted something didnt happen. Never would anyone sue over this. ITS just plain silly. If I didnt have 100% confidence i wouldnt have charted the way I did. Im sure there are a lot of sloppy nurses who do chart without doing. Im just rambling here now but in my 20 years ive seen stuff you wouldnt believe coming from RN's.
    When I was a new grad I was abused badly by the women who "eat their young". my first employer even kept my last check at a nursing home when i left. I put in 2 weeks notice but i was new and she "found" a couple of simple mistakes new grads typically make and threatened to turn me in to the board. I caved and gave her 2 weeks of pay. its a shame nursing is like this. I love being a nurse but the profession still needs a serious cultural makeover. Lawyers and the board can threaten all day long but at the end of the day they have to prove gross negligence or fraud and in my case itll never happen. Ill bet my license on it. Thanks again.
    greg
  6. Visit  Batman25 profile page
    0
    Now that you've been advised not to do it just refrain from it in the future. This really isn't something you should be doing so just live and learn. I would tell your boss it won't happen again and hopefully it just ends there. You should be given a chance to rectify this action before they go to the BON. That seems fair and appropriate.
  7. Visit  BabyLady profile page
    2
    Quote from Batman25
    Now that you've been advised not to do it just refrain from it in the future. This really isn't something you should be doing so just live and learn. I would tell your boss it won't happen again and hopefully it just ends there. You should be given a chance to rectify this action before they go to the BON. That seems fair and appropriate.
    I agree with this...now that you know your facility pitches a fit over this, I guess it was a lesson learned.

    However, I feel fully confident that if they were not bluffing about going to the BON (I still think they are), the BON is going to tell them that unless your facility is claiming you charted something falsely (which you did not), then they are wasting the Board's time.

    As you can see, just from the board, if this many nurses disagree that what you did is a violation or not (I don't think it is, as long as what you copy is true and would not vary from what you would hand write), I am sure the BON will feel the same way.

    They never discussed this issue in school, that is for sure.

    A good discussion for all, nevertheless.
    Tampabay-b and wooh like this.
  8. Visit  morte profile page
    1
    having worked long term care....yes, 10 patients certainly CAN have the same basic note! I wouldnt have a problem with the OPs actions, given the charting format at his institution.
    wooh likes this.
  9. Visit  Mrs. SnowStormRN profile page
    0
    Quote from morte
    having worked long term care....yes, 10 patients certainly CAN have the same basic note! I wouldnt have a problem with the OPs actions, given the charting format at his institution.
    The OP works in Psych not LTC. Different atmosphere.
  10. Visit  chevyv profile page
    2
    I work in psych too and I can tell you all that yes, most of my pts sleep through the night and I chart that on all of them, same note almost word for word. My 15 minute checks are also almost word for word. So and so remains on q 15 minute checks for such and such. No bxs noted or reported this shift. Although I'm glad nothing happened, I'm so past the point of trying to say the same thing differently night after night. I wouldn't have printed and pasted though. We do paper charting and the thought never occurred to me.
    Tampabay-b and wooh like this.
  11. Visit  mazy profile page
    1
    This type of charting would not fly in any of the LTC facilities I have worked at. The way that paper charting tracks time, date info is to maintain a continuous flow of nurses notes, all dated and timed. If a nurse misses a charting note, they have to go back into the nurse's notes, date their entry at the time it is being added, and then notate that it is a late entry from a prior date. Sticking a separate piece of paper in the chart, there is no proof of when that note was written.

    The only deviation from that would be the prepared skilled charting notes where you would have a form to fill out but that requires a very detailed assessment and not just a few lines of notes such as the OP is describing.

    Whatever the intentions of the OP, good or bad, the fact is that you cannot disrupt the flow of charting information with separate pieces of paper, and so it was a mistake to do that. The OP may have saved a lot of time doing it but he has used up several days in trying to justify his mistake and I imagine that he will use up a lot more time trying to argue his case with the DON.

    Better to just be aware of policy-- OP states he has been a nurse for a while so he should be familiar with policy -- and just save everyone a lot of headaches and follow the rules.
    Mrs. SnowStormRN likes this.
  12. Visit  ZippyGBR profile page
    0
    Quote from iNurseUK
    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.
    well you are in a small minority there i suspect.
  13. Visit  morte profile page
    0
    Quote from mazy
    This type of charting would not fly in any of the LTC facilities I have worked at. The way that paper charting tracks time, date info is to maintain a continuous flow of nurses notes, all dated and timed. If a nurse misses a charting note, they have to go back into the nurse's notes, date their entry at the time it is being added, and then notate that it is a late entry from a prior date. Sticking a separate piece of paper in the chart, there is no proof of when that note was written.

    The only deviation from that would be the prepared skilled charting notes where you would have a form to fill out but that requires a very detailed assessment and not just a few lines of notes such as the OP is describing.

    Whatever the intentions of the OP, good or bad, the fact is that you cannot disrupt the flow of charting information with separate pieces of paper, and so it was a mistake to do that. The OP may have saved a lot of time doing it but he has used up several days in trying to justify his mistake and I imagine that he will use up a lot more time trying to argue his case with the DON.

    Better to just be aware of policy-- OP states he has been a nurse for a while so he should be familiar with policy -- and just save everyone a lot of headaches and follow the rules.
    "thank you for all of your comments. To be more clear... the floor is a psych floor and only 4 lines are given for the "shift" nursing note and yes if they slept all night the same note is written on each pt. "
    It would appear that he is speaking of a preprinted form of some sort..so there is NO disruption of chronology.
    And I would hazzard a guess there is no policy....there will soon be one,lol.

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