Search Articles by Topic

Recording information in your patient's chart is an important part of your job as a nurse. There are many ways that charting mistakes can be made. By making yourself more aware of these eight common pitfalls, you can not only avoid making these mistakes but you can also avoid being involved in a lawsuit.

1. FAILING TO RECORD PERTINENT HEALTH OR DRUG INFORMATION

Suppose the patient has a food or drug allergy or a disease such as diabetes or hemophilia. His caregivers need to know this information, but you inadvertently forget to chart it. You not only will endanger the patient, but you could end up in court.

2. FAILING TO RECORD NURSING ACTIONS

Record everything you do for a patient right away. You should chart what you observe and what you do as a result of the observation. Not charting something will impact the next shift. They will not know if the same observation is new or a change since you did not chart the observation. Also, timing is everything. Waiting too long to chart your actions means you have to rely on your memory, which can cause inaccurate or incomplete information.

3. FAILING TO RECORD THAT MEDICATIONS HAVE BEEN GIVEN

Record every medication you give when it is given-including the dose, route and time. Failing to do so could result in a patient being over medicated, which could be terminal in some cases. If you are the one who observes that a medication is ordered and not charted as administered, question it. Make sure that the medication hasn't been given already so that you don't make the mistake of doubling up on the dose.

4. RECORDING ON THE WRONG CHART

You can't be too careful in any situation that might lead to confusion between two patients. They could have the same last name, same room, same condition or even the same doctor. Always match the chart with the wristband of the patient before you do anything.

5. FAILING TO DOCUMENT A DISCONTINUED MEDICATION

If a patient is taken off a medication for any reason, you need to document that order promptly. Not doing so could result in serious complications for a patient, as well as for you if they decide to sue.

6. FAILING TO RECORD DRUG REACTIONS OR CHANGES IN THE PATIENT'S CONDITION

Monitoring the patient's response to treatment isn't enough. You should recognize an adverse reaction or a worsening of the patient's condition, then intervene before the patient is seriously harmed.

7. TRANSCRIBING ORDERS IMPROPERLY OR TRANSCRIBING IMPROPER ORDERS

If you transcribe orders on the wrong chart or transcribe the wrong medication dosage, you can be held liable for any resulting injury. You can also be held liable if you transcribe or carry out an order as it is written, if you know or suspect the order is wrong. You should be familiar with the medications, procedures and activities you are responsible for to know when something isn't right. If you are not sure then ask. Questioning an order is better than making a mistake that could affect someone's health.

8. WRITING ILLEGIBLE OR INCOMPLETE RECORDS

For many nurses this mistake rarely causes a lawsuit, but in the midst of proceedings it can help add to the argument of inadequate care.

So, give your charting careful attention. Make sure you include everything you need to and accompany all documentation with your initials and the time and date. Taking the time to keep good, accurate charts could save you the need to defend yourself in court someday.