Accurate documentation when charting for patients is an essential part of patient care. If errors exist they can be utilized by an attorney in patient negligence cases or by the nursing board once a patient or their family files a complaint. In this blog, we’ll be discussing how and why avoiding nurse charting errors is crucial.
Tips on Charting Correctly
As a nurse learning to complete accurate and comprehensive charting is a vital part of your profession. Here are a couple of tips to make sure your charts are correct.
- If the care was not given, don’t chart it.
- Do not write in margins.
- Do the charting as soon as you can after you complete care.
- Avoid using confusing abbreviations.
- Utilize abbreviations widely accepted in the industry.
- Just chart facts, not personal comments.
- If documentation cannot be complete on a computer, ensure your handwriting is legible.
Electronic Medical Records
Thankfully, most organizations utilize electronic medical records (EMRs), which helps nurses to avoid charting errors. They also increase patient safety and aid in decreasing the cost of healthcare. These digital versions of paper charts are easy to update, and have reminders and alarms to ensure appropriate care is being administered. Like their paper counter parts, they are a very effective way to keep track of patient’s medical histories and medications.
Most nursing students obtain training on EMRs while in school or during their clinicals. This gives students the opportunity to practice different scenarios while being overseen by an instructor.
Examples of Charting Errors
Although there are many ways to incorrectly document a patient’s chart, here are a few examples of errors. All noted below, aside from illegible handwriting, also apply to EMRs.
- Failure to date a medical entry.
- Failure to sign an entry on the medical log.
- Illegible handwriting.
- Putting entries in later.
- Using incorrect abbreviations.
- Putting information on the wrong chart.
Even if it’s just one or two errors it can lead to errors in medication or another serious circumstance. Statistics show there is at least one death every single day in the U. S. that occurs due to a medication error. Annually, about 1.3 million people get injured because of medication errors.
Correctly documenting a patient can mean the difference between life and death. Even simple errors can be disastrous. Improper or error-filled documentation can expose an employer to malpractice lawsuits and cause a nurse to lose their job.
How Chelle Law Can Help
Avoiding nurse charting errors is a critical part of the job, but sometimes they happen. If you have a complaint against you or the Arizona Board of Nursing is investigating a case, it’s critical you have an attorney with experience on your side. Contact Chelle Law to schedule a consultation and learn more about the next steps.