does anyone out there copy charts to save time? - page 7
by lordgregoryrn 11,447 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
- 3May 29, '11 by HorseshoeYou 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.
- 0May 29, '11 by Meriwhen Senior ModeratorI 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.
- 2May 29, '11 by carolmaccas66Illegal 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.
- 3May 30, '11 by BabyLadyQuote from juliecvicurnwe 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.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."
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 juliecvicurnno...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.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.
Quote from juliecvicurnwhat 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".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.
same exact thing with the op...she signed an original signature. that is all that matters.
- 0May 30, '11 by lordgregoryrnthank 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.