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Discussion

Copy and paste in EMR

Is it ethical/legal to copy and paste a 24 hour nursing note from another nurse and when the patient's condition did not change from one shift to the next shift and then just update the VS?

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    No it's not ethical. I don't know about the legality,but you are essentially copying someone else's work.We aren't allowed to do that, especially if it's an assessment.

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    Of course its both legal and ethical and done every single day in all the hospitals I've ever worked at: you are doing a completely new assessment, finding that nothing has changed, update the vitals and the plan of care and voila!

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    Our EHR doesnt even allow us to copy and paste! The only times its very frusterating is when I need to annotate the same thing on a couple of labs (like faxed w/ results to x-ray, md notified, etc etc) and have to keep writting it over and over again. But I would never copy another nurses notes and just insert my own vitals even if it was the same exact thing from last shift but that's just me. If its legal and allowed in your hospital and your comfortable doing it then do it.

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    Depending on the EMR being used,I train an EMR where you can copy the last assesment into another column. Some facilities disable this feature and others keep it in place for the end-users to use.

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