plagiarism??

In an LTC I used to work in, weekly summaries of residents were somewhat randomly assigned by room # and shift that does them. Part of the charting was to include where they ate their meals, activities they partook in, etc. As I worked from 6p to 6a, I was not there to witness meal times and would have occasion to look at others charting to find the answers to questions like that.

During some of this recon, I began to notice that portions of MY weekly summaries were starting to appear under the names of other nurses. I have a VERY distinct style of charting, including my verbage. I asked one of my friends/fellow nurses about it and she said "Oh yeah, we all copy and paste and you write awesome summaries! All of us love doing summaries on someone you've already done!"

I wanted to be flattered, but I was also suspect that a whole of copy/pasting was happening without the benefit of a true hands/eyes on physical assessment actually being completed. I'm not sure that what my co workers were doing falls under the heading of plagerism, but I do think it was pretty damn lazy!

Eh. If it's accurate, then OK. If it isn't, then big NO-NO.

I copy other people's charting all the time in the computer and change it to fit the current clinical picture. It saves me hundreds of clicks and many minutes. This is EMR based charting, though, where it's 99% point-and-click.

I read doc's notes all the time that are obviously copied, because most of the docs I work with are foreign born and have unique syntax.

Honestly, with all the corner-cutting, lower reimbursements, focus on productivity, and higher acuity, I'm surprised any one does any original work these days. Nobody has time.

In the LTC facility where I worked most recently, nurses were expected to write a narrative note on every resident for every shift in addition to point-click assessments. I would copy/past my own notes just to cut down on time spent typing. Of course, I changed details when necessary and wrote notes from scratch to describe incidents. I didn't use others nurses notes simply because I preferred my own format. I wouldn't consider it plagiarism but I also don't consider it best practice. I only did it to help manage an unreasonable work load.

Not plagiarism but not really the best thing to be doing either. Unless it's 100% still accurate for the next nurse (who is copying), then it could be inaccurate/falsified charting.

Forget about plagiarism. It is negligent behavior and false documentation to copy and paste another person's EMR notes. Just because "everyone is doing it", does not make it right. Lawyers and forensic analysts would have a field day in court with this info. Someone, or some agency, with enough resources can make a case out of the preponderance of evidence.

I think it seems trivial and petty. I'm all for making everyone's job a little easier so if my notes were accurate and not much has changed in the patients condition then I say go for it. I'm not going to whine and complain about somebody else copying my notes. It's not like I wrote the notes to get on the New York best sellers list. I mean geez......

Is this what I have to look forward to working around

I work in LTC and have to write medicare notes daily for the same people who do not change from day to day. So yes, I copy/paste usually my own previous notes and just change the relevant daily findings like VS and add any new pertinent information. There are only so many ways to says to say the same thing every day.

As others have said though, if you do this please proof read before submitting your note. It looks pretty silly to keep referencing the same thing in a note days or even weeks after it happened!

Forget about plagiarism. It is negligent behavior and false documentation to copy and paste another person's EMR notes. Just because "everyone is doing it", does not make it right. Lawyers and forensic analysts would have a field day in court with this info. Someone, or some agency, with enough resources can make a case out of the preponderance of evidence.

Why?

Let's say the pt has his eyes closed, and his inspirations are regular.

At 2100, you write "Eyes closed, respirations regular".

At 2200, I write "Eyes closed, respirations regular".

Does it matter whether I cut and paste it vs freehand write it?

Or should I write the same thing, but phrase it differently?

I call this laziness. Write your own narrative of what happened on your shift. I see notes all the time that are not accurate because of copy and paste.

On Wednesday:

Plan: "OR Thursday."

On Friday:

Plan: "OR Thursday". But the patient just went to the OR yesterday and this is no longer his plan. I see stuff like this every day.

day 1 of hospitalization for fever and neutropenia

Plan: "IV antibiotics and daily GCSF until count recovery."

Pt's counts recover and he is to start his next cycle of chemo 10 days later, which is noted elsewhere in the note. At the bottom, plan: "continue antibiotics and daily GCSF until count recovery."

I have seen physicians, particularly house staff copy and paste their own notes, day after day. This is one of my top complaints about electronic records. By doing so, they have not captured that IV ABXs were D/C'd, a foley a D/C'd, a diet advanced etc, etc, etc.

OP, you need to do your own assessment and make your own note. There can be lots of changes to condition in the course of an admission and facility stay.

Plagiarism is poor practice in this instance.