does anyone out there copy charts to save time? | allnurses

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
  2. Visit  lordgregoryrn profile page

    About lordgregoryrn

    Joined May '11; Posts: 7; Likes: 2.

    80 Comments so far...

  3. Visit  caliotter3 profile page
    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. Visit  lordgregoryrn profile page
    0
    thank you for answering. do you know of any law i broke ?
  5. Visit  caliotter3 profile page
    0
    Check your nurse practice act.
  6. Visit  JulieCVICURN profile page
    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. Visit  gcupid profile page
    1
    LoL! Every minute counts in nursing....
    Lovely_RN likes this.
  8. Visit  freemirini profile page
    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. Visit  StrwbryblndRN profile page
    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. Visit  Whispera profile page
    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. Visit  BabyLady profile page
    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.
  12. Visit  BabyLady profile page
    0
    Quote from JulieCVICURN
    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.
    So what would have appeared to be falsified?

    I would guess that HAND written charting would be easier to falsify than copies that are signed. If you really wanted to falsify something, all you have to do is toss the original, get a new sheet and fill in what you need. Original handwriting is very detectable.

    You can't do that with a copy.

    The purpose of charting is accurate information...as long as the patient identifier is there, the information is accurate and bears an original signature, it should be rendered as valid.

    Electronic charting is no different...the same thing appears on the screen over and over again and I can go back and change any of it I want...what we PRINT is in the chart..our printed copies DO NOT show that I made ANY corrections.
  13. Visit  linearthinker profile page
    10
    Are you nuts? Of course it was wrong! You have to have original notes in charts, not photocopies. Good luck luck defending that bone headed move. I don't think you have a leg to stand on. If I were you I'd hang my head in shame, beg forgivness, say 100 Hail Mary's, and promise to never, ever, ever do it again.
    Batman25, joanna73, LadyinScrubs, and 7 others like this.
  14. Visit  dthfytr profile page
    1
    As long as you really did all the patient checks I don't see the problem. You didn't falsify anything. Unless the note itself is inadequate (subjective as it may be) all you did was free yourself from some repetitive charting time so you could spend more time doing patient care!
    wooh likes this.


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