EdieBrous

So this is one of the dangers of having more than one chart open at a time, as well as copying & pasting. It can create a nightmare for the nurse accused of falsified documentation.

Well my lane is defending nurses who are in trouble and some just specifically for copying & pasting so you might want to engage in a better practice here. Just refer to the earlier note & say if there are changes or not. You will be easier to defend if there is a problem.

" this is how it is done" will not be an effective defense if you are before the nursing board or in court. I don't need to practice within standards because we just don't is not going to help you in any way.

It is actually not OK to copy/paste. It is not safe practice, undermines the credibility of the medical record, and is not compliant with regulations or nursing best practices. The exact same note over & over again is precisely the problem. The better practice is to simply refer to the earlier note & say no changes from above, or no changes from above with the exception of. Each entry needs to look like an actual entry. If it is the exact same note over & over again there is no way to know if the provider actually saw that patient at that time or not.

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

Probation or suspension? You can work on probation or with a stayed suspension. You just can't work or hold yourself out as a nurse during an actual full suspension. And where do you want to work? Also in California or somewhere else?

Nurses ARE disciplined for social media posts - free speech or not. I suggest that you get a consultation with an attorney who does licensure defense work in your state so you are prepared if it does happen. And if you are worried about getting into trouble for what you post on line, maybe stop posting on line and get actual legal advice.

It is NEVER OK to falsify a medical record. See if that is what you are being asked to do, or if you are being asked to explain "the hole" and if your boss actually does want you to falsify the record, tell her you would like a meeting with her and HER boss to see if that is really the direction the organization wants to go in. The facility is better off with deficiencies that can be corrected than with allegations of record falsification and billing fraud. And it isn't her license here, it's yours. Willing to bet those directions are not in writing.

Get legal advice before talking to anyone. Nursing board investigations are no joke and you should be represented.

Did you actually see the lab report?

Get the advice of an actual licensure defense attorney in Kansas.

Copy & paste or cut & paste does create potential legal, clinical, and reimbursement problems. The better practice is to refer to the previous note and just say "no changes from" or "as above." Cloned notes can look like falsified documentation, removes original source, is not accepted by the CMS, and can perpetuate inaccurate information. Most employers have a policy against it for those reasons. https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf

Actually you did, but whatever. Just trying to be constructive rather than argumentative. Take care.

Again, missing the point. She needs to be held accountable. Not debating that. But don't stop there. Look at lurking dangers the investigation discovered and take steps to prevent the next horrible death that is waiting to happen as well. It is not either/or.

Again, it is very simple to think the problem is fixed by blaming her alone. People proofing just means redundancies are built into processes so when human error does occur, there are protective mechanisms in place to prevent harm. We used to keep KCL as floor stock next to the sterile water and normal saline for diluents. It was very easy to pick up KCL by mistake. We could just blame the nurse who picked it up by accident for not looking at the vial, but that would not prevent the next nurse from making the same mistake. We removed it from floor stock & stopped placing them together. That is not relying on technology - it is examining all contributing factors, evaluating foreseeable mistakes, and changing systems/processes/workflows. I think if you actually read the corrective action plan, you will see that many other dangerous mistakes were waiting to happen. It is not either hold her accountable or make the system safer. We have to do both.