Following nurse documentation best practices helps keep your patients safe and ensures that you are complying with your employer’s policies – and avoiding potential legal consequences such as a malpractice lawsuit.
Working in healthcare can be fast-paced and stressful. In a single hospital visit, a patient may interact with multiple healthcare professionals who will make notes in their electronic health record (EHR). It is critical to follow nurse charting strategies to prevent lapses in communication that may result in patient treatment errors and legal trouble that could irreparably damage your career.
Here, we examine four additional nurse documentation errors that nursing professionals should be aware of. Be sure to check out Part 1 of this series!
1. Recording on the wrong patient’s chart
Description of Error
Given the sheer volume of patients the average hospital commonly treats at a time, it is possible that a nurse may confuse one patient with another—an honest mistake with potentially dire consequences. As such, nurses should take extensive precaution when validating all the individual details that might cause two patients to get mixed up: similar names, similar conditions, physical proximity, or even having the same attending physicians.
Example Scenario
Consider an instance where a nurse had two unrelated patients who happened to share a last name. Mrs. B. Moyer and Mrs. C. Moyer were on the same unit. Mrs. B. Moyer was being treated for severe hypertension; Mrs. C. Moyer for acute thrombophlebitis. Mrs. C. Moyer’s doctor ordered 4,000 units of heparin for her.
The nurse mistakenly transcribed the heparin order onto Mrs. B. Moyer’s chart and administered the heparin to the wrong patient, and as a result, Mrs. B. Moyer started bleeding. This, of course, would expose both the hospital and the nurse to malpractice liability.
Explanation
When there are two or more patients with the same name, be sure a different nurse is assigned to each patient and develop a system of flagging the patients’ names and medication records. And always double-check wristbands before giving medications.
2. Failing to document discontinuation of a medication
Description of Error
If a patient is scheduled to be taken off a medication after a given period of time once therapeutic effects have been achieved (or before adverse ones come about), it is essential to document this detail so that doctors, nurses, and patients are all aware.
Example Scenario
For example, a doctor once suspected that his patient had developed an ulcer after habitually taking high doses of aspirin for arthritis. The doctor summarily ordered discontinuation of the drug to avoid further aggravation of the ulcer, but the attending nurse at the time neglected to record this detail into the patient chart. As a result, this detail never made it back to the other nurses on duty, who continued administering the patient aspirin and exacerbating the bleed, as the doctor had warned. Eventually the patient’s ulcer deteriorated to the point of requiring a partial gastrectomy, after which she successfully sued the hospital for the nurses’ negligence.
Explanation
Adopting the simple practice of cross-checking doctors’ orders and medication sheets can prevent mistakes likes these.
3. Failing to record drug reactions or changes in the patient’s condition
Description of Error
Monitoring a patient’s response to treatment isn’t enough. Once a nurse recognizes an adverse drug reaction or a worsening of the patient’s condition, it is their responsibility to proactively intervene (or notify someone better equipped to do so) and then document the occurrence to prevent it from happening again.
Example Scenario
For instance, a patient once complained of nausea, dizziness, abdominal pain, and itchy skin shortly after receiving his first 100-mg dose of nitrofurantoin macrocrystals (Macrodantin). Having administered the same drug to many patients with no adverse reactions, the attending nurse did not take concern to any of the symptoms the patient was reporting. By evening, after two more doses of the same medication, the patient was suffering from vomiting, high fever, urticaria, and early symptoms of shock. The patient later sued his nurse for negligence.
Explanation
The fact that most patients don’t have adverse reactions to a given drug shouldn’t dull nurses’ vigilance in administering it. Every drug has side effects, and contraindications can vary drastically from one person to the next based on their entirely unique internal conditions. So, observe patients closely, always consider the possibility of adverse reactions when a patient reports new symptoms, and follow up promptly and proactively.
4. Transcribing orders improperly
Description of Error
Nurses are responsible for familiarizing themselves with their patient’s medications, procedures, and activities, as well as documenting ongoing developments in treatment for others to reference. With this level of responsibility comes the potential for malpractice liability risks. If a nurse transcribes orders on the wrong chart or transcribes the wrong dose, they may be held liable for any resulting injury. Nurses can also be held accountable if they transcribe or carry out an order as it’s written if they know or suspect the order is wrong. As these instances can entail serious legal consequences, nurses must prioritize understanding the details of their patient’s treatment well enough to recognize when something isn’t right.
Example Scenario
Sometimes, a nurse can carry responsibility for blindly transcribing a doctor’s mistakes. For example, one doctor intended to order 0.5ml of atropine for a patient. However, the doctor had forgotten to write the decimal point on the order and the transcribing nurse proceeded to request a 5ml dose, though she had suspected that there may have been a mistake. In this case, the nurse can potentially be held liable for negligence in deciding that the doctor probably knew best and failing to consult her own best judgment.
Explanation
Medication errors like this are among the most common in the entire healthcare industry. So, if you suspect that a mistake or miscommunication has occurred somewhere in a patient’s treatment or prescribing information that could put them at risk, do not hesitate to double-check.
Conclusion
It’s natural in nursing settings to feel like there isn’t enough time to check every detail, but investing in thorough nursing charting practices is never a waste of time. Detailed nurse notes save lives, and consistently getting them right makes patients feel safe. In addition to promoting patient safety, strong medical charting practices help prevent malpractice lawsuits. . Knowing that thorough nurse charting takes time, it is most practical to be strategic with efforts. Look for efficiencies, work with colleagues, and use best judgment and ingenuity to find ways to work effectively while still maintaining a high quality of care. By remaining cognizant of the charting errors outlined above and implementing best practices to ensure against them, nurses can prioritize the safety and wellbeing of both their patients and their own careers.