does anyone out there copy charts to save time? - page 6
by lordgregoryrn 11,298 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
- 2May 28, '11 by NicuGalSorry, you were in the wrong. Things that are copied, such as standing orders, etc are APPROVED by the facility and are reviewed every 2 years. Nurses notes, that are handwritten are to be original, not photocopied. Tough lesson to learn.
- 1thank 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. In fact I copied word for work a proior note from a house supervisor when I made my "copy note". of course if they got oob and came to the nuse station or did something unusual i charted it. but all of the pts that I used precopied notes on did nothing to warrent a note. This is 3rd shift. the nurse on 2nd shift charts the assessment like breathing , VS etc. every night a tech charts on pts every 15 min. its a check off that says they were checked on and in bed or wherever.
it saves about 30 min a shift but at 5am im preparing for the end of the shift, everyone waking up and docs coming in, 2. you cant read my hand writing at 5am, 3. wring the same thing 15 times in a row puts me to sleep.
does anyone know the law that says all chart need to be automated by 2014
- 4May 28, '11 by JulieCVICURNBut that is not what happened on HER shift. When the OP signed off they were A-Ok.
Doesn't work like that in the U.S.A. There is always something to be charted. Documentation is vital here.
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. 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.
All facilities must have EMR's by 2015 is the basic general rule, although it's quite a bit more complicated than that. If you google ARRA, Meaningful Use or go to HIMSS.org you should be able to find all kinds of info about it. If they don't, there will be penalties in the form of reduced or denied Medicare/Medicaid payments among other things.
LordGregory, maybe you could use this "event" to suggest to your facility that a form be created for checking off common things like this to include in the notes. The problem here is also your facility policy. If you had a policy in place that allowed for using an overnight quality of sleep checklist, you'd be in the clear.Last edit by JulieCVICURN on May 28, '11
- 0another thing to give more info---- these are psych pts, its night shift, and our goal it to keep them asleep and not wake them- so no assessment is needed other than checking once a shift to make sure they are alive.- the techs peek in every 15 min to prevent suicide.
- 1thanks, im an average nurse doing an average job. i was super nurse for a long time but am about to retire soon- would rather retire on a positive note however.
i would never dream of falsifying a chart or illegal activity. You can be sued and lose money or jail for that.
what i did is simply what other hospitals are doing, but in a different way. AMR
I have seen AMRs coming in from er's where boxes are checked and sometimes the boxs checked say no suicidal or homicidal thoughts and the person is an admit because they just took a bottle of pills and a knife to the spouse.
last week i read one from an m.d. whos evaluation was .... no sign of uti and when i read the labs she obviosly had a uti... bacteria wbc's etc. I left a note for the am doctor and 2 days later when i came back to work she was on bactrim
- 0May 28, '11 by Mrs. SnowStormRNQuote from lordgregoryrnReally? I've worked in psych for 8 years, sometimes nights - and I still assessed them by walking into each room to do my checks (and yes the psych techs do these checks as well on my unit, we also have a check off list. We also must type a nursing note on each client every night). Many psych patients do not sleep well. At night our schizophrenics often wandered, many had become tolerant to sleeping pills as well as anxiety meds. At night I have walked in on patients who have gone into other rooms, and had to be redirected. I've found a patient experiencing tardive dyskinesia during the night. Wow! You work on a pretty calm psych unit. KUDOS to you. Because when it comes to behavioral charting on a psych unit, usually 15 patients are far from the same, but that's just my opinion.another thing to give more info---- these are psych pts, its night shift, and our goal it to keep them asleep and not wake them- so no assessment is needed other than checking once a shift to make sure they are alive.- the techs peek in every 15 min to prevent suicide.
- 3May 28, '11 by woohQuote from JulieCVICURNUnless the attorney has a class action suit for all of those patients, that attorney isn't going to see all the charts.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."
My typical third shift note after the assessment back in the day on a med/surg unit for my rounds: Pt resting quietly with eyes closed, respirations even/unlabored, no s/s acute distress noted. This would typically describe everyone. If it didn't, I'd chart what was different, which it sounds like the OP would have done if something was different.
Now that I've got electronic charting, we have all sorts of "smart phrases" that you can pick up the system's or create your own. I've got standard ones that I made for my discharges and education, because otherwise I'd type the same thing. The MDs copy the previous day's note and half the time don't make any changes except where they're keyed to pull up the last labs (so the MD didn't even change that, the computer did.)
Copy and paste is great. If it's different, chart the difference, if it's the same, I'm not going to switch a couple words to make it "look" like I assessed the patient. And if that would fool someone, I can point out nurses with beautiful charting that don't do half the stuff they chart they did. If my boss doesn't believe my charting, we've got bigger problems than copy and paste.
To me, the OP came up with a creative solution. Probably should have run it by the powers that be at his facility before trying it though. I wish him luck in this fight.
- 4May 28, '11 by BluegrassRNI think the issue here is it is not the standard for the facility. I also see an issue in the interruption in the flow of charting, if you're inserting a single sheet of paper with 2 lines in as it's own sheet, rather than documenting on the continuous record.
Humble yourself a bit. Meet with your director, tell her your sorry you went outside of the facility standard. Tell her honestly that you thought you were thinking outside the box, being creative in your time management. Apologize, and then offer to do some research on how other, similar facilities have updated their charting forms to save time while still covering all important details....an easy to read check list, for example.