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.
It's pretty standard for Social Workers to refer to the Nursing Assessment and Plan, using your written assessment and plan in the SW note is one reason why you chart it; for others to use in the care and planning for the patient. This can either be done by re-phrasing your charting and potentially misinterpreting it, or copy and paste which is the most accurate option. You don't own the charting you do on a patient, the patient does, the best plan is probably to get over it and be glad that someone found a Nurse's note useful.
That's cool and all, but I am positive that copy/paste is used in place of actual assessment by many.
I've started to wonder about this on my floor. Being a new grad, I'm not always confident about what I'm finding on a pt, usually breath sounds, sometimes the degree of edema or pulse strength. Our system allows the recall of values so you can automatically complete the section with what was charted previously so sometimes I look to see if the last RN was hearing the crackles I think I'm hearing (although obviously it could be a new development from the last assessment). However, I found on one of my pts a couple nights ago, that it really seems like people are blowing thru their assessment & possibly just recharting the same previous findings of others. This elderly gentleman, 84, (like most) did NOT have GOOD or even fair turgor (expected), had skin breakdown, was on fluid restriction w/renal issues/foley/low output (therefore pretty sure voiding cannot be charted "w/no difficulty".) However, over and over (even by the more seasoned day shift nurses), skin was clean/dry/intact w/ good turgor, no voiding difficulty, lungs clear (though I thought diminished & charted it.) This was also a pt who it was thought was having diarrhea, given immodium regularly for the past few shifts, when it was actually an impaction that was taken care of (thank goodness! lol) just before my shift started.
that's cool and all, but i am positive that copy/paste is used in place of actual assessment by many.
i've started to wonder about this on my floor. being a new grad, i'm not always confident about what i'm finding on a pt, usually breath sounds, sometimes the degree of edema or pulse strength. our system allows the recall of values so you can automatically complete the section with what was charted previously so sometimes i look to see if the last rn was hearing the crackles i think i'm hearing (although obviously it could be a new development from the last assessment). however, i found on one of my pts a couple nights ago, that it really seems like people are blowing thru their assessment & possibly just recharting the same previous findings of others. this elderly gentleman, 84, (like most) did not have good or even fair turgor (expected), had skin breakdown, was on fluid restriction w/renal issues/foley/low output (therefore pretty sure voiding cannot be charted "w/no difficulty".) however, over and over (even by the more seasoned day shift nurses), skin was clean/dry/intact w/ good turgor, no voiding difficulty, lungs clear (though i thought diminished & charted it.) this was also a pt who it was thought was having diarrhea, given immodium regularly for the past few shifts, when it was actually an impaction that was taken care of (thank goodness! lol) just before my shift started.
just makes me wonder....
social work copying initial nursing assessment for hospice admission is one thing, but......
identical detailed nursing assessment "notes" (vs electronically populating a field with set responses) for a patient that are completed on sequential shifts should raise a red flag on those assessments.....so no, that would not flatter me.
the reality of what nu rn describes happening should set off alarm bells for anyone who considers patient advocacy part of their role. good for you nu rn for noticing and caring.
.thumb.jpg.85a3957354ce9d2e3ada13e4a6240b10.jpg){kind=small}
I was absolutely furious.
MunoRN, RN
8,058 Posts
It's pretty standard for Social Workers to refer to the Nursing Assessment and Plan, using your written assessment and plan in the SW note is one reason why you chart it; for others to use in the care and planning for the patient. This can either be done by re-phrasing your charting and potentially misinterpreting it, or copy and paste which is the most accurate option. You don't own the charting you do on a patient, the patient does, the best plan is probably to get over it and be glad that someone found a Nurse's note useful.