accused of plagiarism

ponderingDNP · Feb 2

Sometimes, in long term care environments, whether you enter the same note verbatim or copy and paste it, the only thing that changes is the date and time on this stable population. I will be so happy when more facilities realize that it is safer to chart by exception in my opinion (chart daily, weekly or if something actually changes with the resident). As for your punishment, I believe you have received the max for your actions if nothing else happened to the resident and even in that, I think the do-not-return was overkill. I have never seen that type of response before.

I would venture a guess and say that a coworker resented your presence (assuming you are an agency nurse as indicated by the Do Not Return) and/or your time-management approach to care.

Moving forward, be sure to follow facility protocol for documenting in patient records.

allnurses Guide · Feb 3

megan morin said:

I recently picked up a shift at a nursing home and the nxt day got notified I was a dnr due to copying and pasting my progress notes. can I get in trouble for this?

Well it's not plagiarism if you are doing this with your note. I use templates on the job daily. Once I copy and paste I go into the note and personalize it to the patient's condition and needs.

Nursing homes have rigid charting requirements, so maybe that's why you were let go.

Hppy

chare · Feb 3

It is common practice for physicians to copy the previous day's progress net, regardless of who wrote it, and use this as the basis of their daily note.

So long as appropriate edits are made and the note is accurate, how is this a problem?

toomuchbaloney · Feb 3

megan morin said:

I recently picked up a shift at a nursing home and the nxt day got notified I was a dnr due to copying and pasting my progress notes. can I get in trouble for this?

First, what you describe is not plagiarism. Second, what you did is not against the law, but may be against facility or company policy.

What is your relationship with the parent company of that facility? That will influence whether or not you are "in trouble", but honestly, it doesn't sound like something that should involve "trouble".

JKL33 · Feb 3

These people wouldn't know what to do with dot phrases/auto-replace...?

And what do they do if by some miracle a patient is "resting with eyes closed, resps even and unlabored" two nights in a row?

Wuzzie · Feb 3

JKL33 said:

These people wouldn't know what to do with dot phrases/auto-replace...?

I had the very same thought. I have sooo many "smart phrases" and "smart lists" I use every single day. It massively improves my efficiency.

Career Columnist / Author · Feb 4

This lack of critical thinking in nursing leadership is discouraging

EdieBrous, BSN, MSN · Feb 7

Copy & paste or cut & paste does create potential legal, clinical, and reimbursement problems. The better practice is to refer to the previous note and just say "no changes from" or "as above." Cloned notes can look like falsified documentation, removes original source, is not accepted by the CMS, and can perpetuate inaccurate information. Most employers have a policy against it for those reasons. https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf

Career Columnist / Author · Feb 7

EdieBrous said:

Copy & paste or cut & paste does create potential legal, clinical, and reimbursement problems. The better practice is to refer to the previous note and just say "no changes from" or "as above." Cloned notes can look like falsified documentation, removes original source, is not accepted by the CMS, and can perpetuate inaccurate information. Most employers have a policy against it for those reasons. https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf

Thank you, I like your explanation. That's what they should have told the nurse, and then backed it up with a policy as well as included the information in orientation.

Telling the OP her/his wrongdoing was "plagiarism" is misguided.