Nurses Notes plagiarism at work such a thing?

[Lanipeach]

Any one ever been accused of plagiarizing another nurses nursing notes. I don't mean whole paragraphs, just a few phrases here and there, like "ambu bag at bedside" or "I & O cathed x 1 for clear,yellow urine" or trach care performed. Pt. tolerated well". In my state SC the SBON does not have anything regarding same. Just want to know what is the general census regarding this.

Thanks!

[wooh, BSN, RN]

Of course it's plagiarism. Also should avoid self-plagiarism. Sure, after 100s and 1000s of patients it gets difficult to come up with a new way to say that they are "A&Ox3," (Nursing notes, patient name redacted, Nov. 3, 2005), but we MUST find a way!!!

[anonymurse]

It's not plagiarism because we're paid to chart. That means the words belong to the hospital that paid for them. And if someone else cuts and pastes my words because it describes a situation that's unchanged to a "T," then that belongs to the hospital, too, and in addition, that person saved our employer money.

[mhy12784]

One thing that the system that my hospital has, is you can save abbreviations and when you type them out it will change the abbreviation or shortcut into the full phrase.

like I could set it up that whenever I type " pt100%" that it will automatically turn into "patient is aox3, ambulating on their own unassisted, performs adls etc etc)

And you could also download other users shortcuts as well for your profile.

So you frequently get people using verbatim phrases in each others notes.

As long as they're applicable I see no issue.

The only type of "plagiarism" I potentially see is if you just literally copy pasted another nurses note for your patient from a prveious date and pasted it again as yours, without actually assessing them.

Of course thats more like negligence and falsification of documents than plagiarism

[imintrouble, BSN, RN]

I learned how to chart well, from an exceptional "old" nurse I followed every day. I literally adopted words and phrases verbatim. I didn't see anything wrong in it. I still don't.

What makes me smile is when I read the notes of new nurses we hire, and I see those same words and phrases. Only they get them from me.

[pinkiepieRN]

There are just only so many ways to phrase things. For many of the long term residents at my facility, similar things apply throughout shifts for multiple residents. "A&Ox3. Verbal and responsive to stimuli. Tolerated all due medications without incident. Treatments completed - resident tolerated well. Denies any concerns or complaints. No pain or discomfort noted at this time." For someone on ABT, I chart "Resident continues on ABT for _____. No s/sx of complication noted. Denies s/sx of _________ (whatever infectious process). VS as follows..."

Nursing care isn't that original and it's not as if we really have time to re-invent the wheel, so to speak. Obviously your note caters to your patient's unique circumstances, situation, symptoms, disease process, wound status, etc., but as long as your documentation is complete, I don't see an issue with notes looking similar if not identical.

[twinkerrs]

Joint commission and other accreditation bodies look for key phrases when they look at documentation. So I don't see how it's plagiarism Obviously those bodies consider it ebp to use certain phrases in documentation.

[xoemmylouox, ASN, RN]

What raised this question? Someone making an issue out of this at work, an issue brought up in a class, or something just on your mind? I think that you can learn great phrases from others charting. I don't suggest copying & pasting, but using phrases is fine. As mentioned before there are only so many ways to say the same things.

[blondy2061h, MSN, RN]

Of course it's plagiarism. Also should avoid self-plagiarism. Sure, after 100s and 1000s of patients it gets difficult to come up with a new way to say that they are "A&Ox3," (Nursing notes, patient name redacted, Nov. 3, 2005), but we MUST find a way!!!

"Patient alive, awake, alert, enthusiastic! Oriented to person, place, time, and the beat!" (Nursing Notes, patient name redacted, January 4, 1993)

[klone, MSN, RN]

OP, you need to come back and provide more clarification. As a former writer who is now a nurse, I find the idea that one could plagiarize nurses' notes to be quite amusing.

Was someone accused of this, and by whom?

[klone, MSN, RN]

I do like "Alive, alert and enthusiastic!"

[wooh, BSN, RN]

Isn't "alive" a medical diagnosis? Don't want to act outside our scope! :)

[ohiobobcat]

"Patient alive, awake, alert, enthusiastic! Oriented to person, place, time, and the beat!"

Love it!!! I'm changing my charting verbage to this!!!