does anyone out there copy charts to save time? - page 9

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  carl5480 profile page
    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.
  2. Visit  JulieCVICURN profile page
    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.
  3. Visit  wooh profile page
    ^^Yep, while perfectly permissible for MDs to use copies of things to save them time and writers cramp, we can't trust nurses to do anything that makes their job easier, because giving ourselves time to do our job makes it look like we're not doing our job.
    Tampabay-b and morte like this.

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