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

Specializes in CVICU.

That does seem rather like overkill. Remediation would be the right path, not punishment.

its not uncommon for 15 out of 20 pts to sleep from 11pm to 5am. we dont wake up the schizoid pts

You are probably okay with the BON if you haven't violated your state's Nurse Practice Act. However, if you have violated the policy of your facility, you can cry all day about it and get as much sympathy as you want on a message board, but you will be just as fired, or just as disciplined as they feel you need to be.

There are laws, and there are policies. Violation of either can get you in serious trouble.

Specializes in Psych ICU, addictions.

I can see why you did it...however I can see why your DON is upset. If someone decided to sue, a good lawyer can argue that you didn't assess one or more of the patients because you used a photocopied note. Or they can say that you falsified assessments, especially if a patient goes south on the next shift. Then it'd be on you to prove that you did assess the patients and that in fact all of them were sleeping and there really were no problems. Photocopied notes look really sketchy.

They fired a night shift nurse from my facility for something similar: she often used pre-filled shift notes that stated that patients were resting quietly with no problems, etc. that she'd sign and date at the beginning of each shift. The facility stated that was falsifying documentation and let her go.

Hope everything works out with your facility and the BON, and best of luck in the future.

Specializes in MCH,NICU,NNsy,Educ,Village Nursing.

Did you check on each patient, or just write? If you wrote without checking/assessisng, you did indeed chart falsely. I understand how "boring" writing the same thing over & over gets---used to do it. But, it's the right thing to do.....

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:

Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

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.

Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

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!

Specializes in NICU, Post-partum.
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.

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.

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.

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

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.

Specializes in NICU, Post-partum.
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.

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