does anyone out there copy charts to save time? - page 8

by lordgregoryrn 11,275 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


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    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.
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    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.
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    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.
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    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.
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    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.
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    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.
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    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.
  8. 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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    Quote from Up2nogood RN
    If I was a nurse manager I would wonder what other corners you cut to save time?
    This is the thought that occurred to me as well. This is very, very obviously not proper procedure, and you are legally setting yourself up for trouble (as you have now seen). Why would you invite this kind of response upon yourself? Was it really worth it for a couple of saved minutes?

    And as others have stated, you do appear to have falsified information, because it's entirely impossible for every single one of those patients to have the same assessment. If you are always writing the same notes on every single patient, then your documentation cannot be up to scratch in the first place. Granted, if you work in a psych unit then the circumstances are different. But you might consider making it standard practice to vary your notes from time to time. Not only does this make the job (mildly) more interesting, but it shows that you ARE actually looking in on your patients, as opposed to just writing that you are.

    As someone else pointed out, you may or may not get into trouble legally over this, as you cannot be proven to have neglected your patients. But within your facility and within the BON, no one who oversees front-line nurses will ever agree that taking it upon yourself to photocopy nurse's notes and insert them into multiple charts is ok. Other people have claimed that "it's ok because we do that with flush protocols" yadda yadda yadda. It is entirely different to have a pre-printed order set vs. handwriting a note on a single patient which is then used for 14 other patients as well. Simply signing and dating does not erase the fact that you are neglecting to treat each patient as an individual instead of as just another one in a group.
    Last edit by carl5480 on Jun 2, '11
    Meriwhen and diva rn like this.
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    It is entirely different to have a pre-printed order set vs. handwriting a note on a single patient which is then used for 14 other patients as well.
    True. I can only speak for my own facility, but although we use many preprinted selective order sets, we do not use a single one that has not been reviewed by an appropriate committee and approved for use after the vetting process. Where I work, you can't just decide to make up a standard form and start using it on your patients, nor can you copy one note over and over and sign it and consider it valid.
    Horseshoe likes this.


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