Wound documentation

[Dolo the nurse]

I'm pretty sure I know the answer to my question but I always like to double check myself. I work in a 360 bed LTC facility and I am the wound nurse for the building. We have 6 units, 1 of which is a STR. If you work in a similar setting, you know that caseload fluctuates. Sometimes  you have so many you can't keep them straight and other times you only have a handful (those times are further and further apart since the pandemic). We are "staff challenged" like everyone else. Lately I've begun to receive pressure to cut down the length of my documentation so I can "hurry up and get it done" and help them in other areas. I have always said, in an emergency pull me to help, absolutely but I have now become the answer to their staffing issues.  I'm a team player and when I've had a "Lule" in my caseload I go do the bigger treatments for the nurses, stop in to offer words of encouragement to my patients or catch up on my family communication. I don't just shop on eBay all day, I find a way to contribute. I was out for 4 weeks over the holiday with pna. When I came back they started assigning extra help to me if they had a light duty or extra nurse to help me get MY documentation done.  The other day they pulled me to do treatments for the house and to cover one of the units for 4 hours then assigned my documentation to a 3-11 nurse who can't complete a skin sheet completely let alone document on an assessment she wasn't even present for!  I told myself I wasn't going to check what she did...if they don't value me, so be it I thought. But my integrity and duty I feel to my patients and families would not allow me to do that so I checked a couple notes.  She literally copied and pasted MY LAST DOCUMENTED note, changed the measurements and saved it.  Now, one particular resident had just come back from the hospital and the admitting nurse never completed the skin sheets so when we saw him during wound rounds we wrote the assessment information on a piece of paper and I agreed to start the skin sheets. I did not get to complete them before I left that day.  They were in my office on my desk. Imagine my surprise when I saw she documented on him too. Literally just copied and pasted my last note with 4 sites identified however, when he re admitted, only 2 of the 4 were still present. Am I crazy for being insulted (putting it mildly) about this? Thought?

[Nurse Alexa, MSN, RN]

I don't think anyone should ever copy your documentation - that is plagiarism and the HCP can face legal action (esp if there is free text that she/he just copy and pasted). You should speak with the HCP personally about copying you and let her know of your concerns 

 

Hope this helps ?