Copied documentation?

Published

  • Specializes in onc, M/S, hospice, nursing informatics. Has 11 years experience.

Grrr... so frustrated! I work with a social worker, and part of our job is to do initial consultations with potential hospice patients.

I was checking some charting yesterday on a patient when we did a visit together, and I found a note in the computer from our social worker... exact wording as my note. It's so blatantly not hers, because she does not use capitalization or correct punctuation (and I do), and I almost always write pretty much the same blurb unless there is a problem or something out of the ordinary. It's just a short three-line note. But I am furious! It's the principle of it.

I need advice. Should I confront her? Should I let it go? Anyone have anything like this happen? Thanks for the suggestions.

:devil:

Blackcat99

2,836 Posts

Just let it go. People do that kind of thing all the time in nursing. It's a compliment to you. They liked what you wrote so decided to use it for themselves too.;)

TheCommuter, BSN, RN

226 Articles; 27,608 Posts

Specializes in Case mgmt., rehab, (CRRN), LTC & psych. Has 17 years experience.

One of my former coworkers made a copy of my generic nurses note and used it to chart on all of her patients that were having no specific issues during that shift. I had no issues with the fact that she had done this.

Sparrowhawk

664 Posts

Specializes in LTC.

Ask her about it...maybe it was a mistake. *doubt it* but you never know

46oldnewrn

59 Posts

Specializes in LTC. Has 4 years experience.

If I am grasping for things to write on a patient that has to be documented on every single day that has been in LTC for months, heck yes I look back in old charting to see if I could pull something out so I am not so redundant. You should be flattered not angry.

vanburbian

228 Posts

Specializes in ER. Has 27 years experience.

Some EHR's actually use smart sets that are identical, except for very specific patient info, and share system wide or within units/specialty arenas.

It can save time, and it can assist with charting by cueing people to write the required info, and not get too wordy, which may lead to no one actually ever reading the note because it's too long.

TiffyRN, BSN, PhD

2,315 Posts

Specializes in Nurse Scientist-Research. Has 30 years experience.

I was about to post about "smart phrases". Some EMR systems have this officially and we are encouraged to share them (especially those nurses that compose particularly coherent and professional sounding documentation).

I agree with the others that this is perfectly acceptable. The only thing I find unacceptable is if a person copies documentation without verifying that all copied is current.

I would find it a compliment if someone used my phrasing especially if this person struggles with such things as punctuation, spelling or syntax. As long as they did their own assessment and such documentation was accurate.

systoly

1,756 Posts

Specializes in LTC, Memory loss, PDN. Has 23 years experience.

Take it as a compliment.

netglow, ASN, RN

4,412 Posts

That's cool and all, but I am positive that copy/paste is used in place of actual assessment by many.

samirish

198 Posts

It would not bother me in the least..

caliotter3

38,333 Posts

That's cool and all, but I am positive that copy/paste is used in place of actual assessment by many.

This would be my concern. But not really my worry, as it is she who would have to justify her actions.

MrChicagoRN, RN

2,589 Posts

Specializes in Leadership, Psych, HomeCare, Amb. Care. Has 30 years experience.

I'd wonder if she's actually doing an assessment.

Personalize the charting a bit to include proper names "lives with husband Sam," or "Mrs Jones agreed to..."

Then see if those entries are unread cut and paste jobs