Ethical dilemma

[Testing1.2.3.]

When reviewing the notes from the previous shift I realized that I had read a patient's note before. I went back over previous documentation and saw that the nurse I was relieving cut/ pasted a note written days before about a different patient. 

The  note was fairly generic and actually seemed likely to be accurate in most descriptions (took meds as prescribed, pain level, etc) but it was definitely cut and pasted. I'm not a supervisor, 
Should I mention this to her and warn her that it's not appropriate nor ethical? Or, report her?  

I should add, she's a fairly new nurse but everything I've seen is that she's a good at her job: responsible, kind with patients, and helpful with colleagues; she's also a single mom with a four-year-old and twin daughters who are two. I would hate to see her get fired... but I'm really torn as what to do.

[chare]

You read a nurse's note, and "realized that [you] had read [that] patient's note before."  And this concerned you enough that you "went back over previous documentation" and found this note in another patient's chart?  And after doing so, you're concerned this was "not appropriate nor ethical?"  You're "really torn as what to do" and are considering reporting her?  Are you serious?  For what?  Perhaps she wrote a template for a generic note format?

Even if she copied the note in its entirety, and it "was fairly generic and actually seemed likely to be accurate in most descriptions," what did she do wrong?  After all, there are only so many ways that one can say "took meds as prescribed, pain level, etc."

I'm curious.  Was entering another patient's chart, even if you were assigned their care, for the purpose of finding the source of a note, a valid reason to do so? 

Perhaps you should report this as well.

[missaretha]

Go work in skilled nursing, where you'll have 25+ resident patients to chart on. You'll  be copying and pasting generic notes, and adding the changes where needed, after one shift. Stay in your lane.

[B52, BSN, MSN, RN]

Snitches get stiches. Just kidding, but there's nothing to snitch about. In my workplace we have templates, so the same note might show up on 100 patients daily.

[ValLyn]

Was it ethical to check someone's work? Are you a supervisor or chart auditor?  Mind the business that pays you. I'm sure if you were doing your job, you wouldn't have time to worry about what others are doing.

[Shannon Marie]

Don't be that nurse! There's nothing wrong with this if the note was accurate. Some chatting systems have a template or dot phrase that you can use to cover all the necessary components of a note. There is nothing unethical about this. What's the ethical for you to go back into the chart that you saw the original note in since it wasn't your patient that day? You have too much time on your hands if you do this.

*Charting not chatting

[Patricia Ordnung]

L

It sounds like she's a fairly new nurse who wants to insure her documentation is complete and worded correctly.  Please tend to your own documentation and leave this situation alone.  

[EdieBrous, BSN, MSN]

Using a standardized template & making necessary changes or additions is one thing.  Actually copying and pasting notes is another.  The better practice is to refer to the previous note & say no changes from above, or as per & date/time of the note. Copying & pasting can look like falsified documentation and is not a good practice.  That function should actually be disabled in an EMR.  It is "cloned documentation" and can create legal problems, inaccurate medical records, regulatory issues, and reimbursement denials. We have known that for at least 15 years.  https://www.ecri.org/Resources/HIT/CP_Toolkit/CopyPaste_Literature_final.pdf

[nightwingcreations, CNA, LPN]

EdieBrous said:

Using a standardized template & making necessary changes or additions is one thing.  Actually copying and pasting notes is another.  The better practice is to refer to the previous note & say no changes from above, or as per & date/time of the note. 

Except they say this was two different patients. And a relatively generic note, so quite possibly coincidence. They don't actually even know that the person even saw the other note.  

 

[Ruth E. Raleigh]

Talk to your immediate supervisor about it as to what to do.  Let them handle it from there.  Knowing about it and not saying something is just as detrimental as being complicit.  Get that monkey off your back.  The reason I am saying this is because not if, but WHEN things come down, ANYONE working with this person will be taken down along with the guilty party. Do not be co-dependent.  Report this behavior.

[kbrn2002, ADN, RN]

If the note was accurate to the patient there is nothing wrong with using a copy/paste template and adding/removing as needed. Have you read any provider rounding notes? They are usually copy/paste, the exact same note over and over again.  with current VS and anything else new added. 

[Ruth E. Raleigh]

In order for a note to be billable to insurances, copy and paste should NEVER be used, not in the hospital, and not in home care settings.