does anyone out there copy charts to save time?

  1. 0
    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

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  2. 80 Comments...

  3. 5
    Stupid move, but I don't see why she was that harsh. I would have had to think long and hard about whether or not to fire you. But I would not have made a complaint to the board about it.
    Batman25, joanna73, DizzyLizzyNurse, and 2 others like this.
  4. 0
    thank you for answering. do you know of any law i broke ?
  5. 0
    Check your nurse practice act.
  6. 15
    I know it wasnt wrong to do but now I have to provide proof that what I did wasnt wrong.
    But it WAS wrong. Maybe you would have written the same thing on every patient, but what you did makes the documentation look as if it's been falsified. If I were a Joint Commission surveyor, I'd have been all over your facility if I found some glaring evidence of negligent charting like that.
    caroladybelle, JustaGypsy, elkpark, and 12 others like this.
  7. 1
    LoL! Every minute counts in nursing....
    Lovely_RN likes this.
  8. 4
    I think it sounds like you were creative and efficient. Lots of people use cut and paste in electronic medical records... Maybe you can explain it in that light...
    punkydoodlesRN, noyesno, Lovely_RN, and 1 other like this.
  9. 2
    I am not sure if this helps but check to see if it is written somewhere that this can't be done.
    I know doctors have standing orders that can be preprinted and become valid once signed. Your method does not seem to be too far off. I would think that as long as the signature is there, what difference does it make.
    Of course docs are different.
    Lovely_RN and Matthew_RN like this.
  10. 4
    I'm not sure you saved so much time, by the time you made the first note, walked to the copy machine, made copies, punched holes in the pages, signed each one, put a name on each page and whatever other patient identifying info you needed, and then put each one in a patient's chart!

    I believe you are outside your facility's policy and procedure rules here and that's where what you did isn't ok. I think if you explain, what you did will be understood, and maybe it could bring about some changes, such as a short checklist for sleeping hours? But, you can't just do changes on your own. Everyone and his uncle and maybe an aunt or two has to approve first. When a surveyor comes in, they jump on things that are done outside what the facility's policy says should be done. It makes them wonder if other things are being done outside of policy...
  11. 1
    I'm guessing, but I would wager she doesn't have a case.

    IF you were going to write the EXACT same thing on each patient anyway? I see no difference between that and protocols that get printed off a computer that we merely sign off on.

    IF anything was different on each patient, she would be right.

    False charting is charting what is not true or never happened...that isn't the case here.
    wooh likes this.

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