7 Common Pitfalls to Avoid in Charting Patient Information

Accurate and complete patient information is essential to providing the highest possible standard of care. Here is simple guidance to keep charting at its best, protect patients from treatment error and prevent potential malpractice liability. 

In healthcare, people’s lives often depend on the accuracy and availability of treatment information. During a single hospital visit, multiple healthcare professionals will make notes in a patient’s EHR, resulting in what sometimes feels like a game of telephone with lives at stake. A few common charting mistakes can lead to errors in treatment—with malpractice lawsuits not far behind. Outlined below are eight of the most common charting mistakes that end up in court along with guidance on best practices nurses can employ to protect both their patients and their indemnity.  
 

1. Failing to record pertinent health or drug information 

It comes as no surprise that maintaining a correct and complete medical history is vital for providing proper treatment. However, the importance of this point is further underscored by the fact that failure to record key details such as allergies, diseases, and current medications can leave nurses personally liable for negligent patient care.  

In one example, a nurse neglected to note a patient’s penicillin allergy during the initial intake process. Without a proper record or indication of the allergy, a hospital intern unwittingly administered what turned out to be a debilitating and ultimately lethal dose of the drug as part of what was by all accounts a standard procedure. It was this one innocent charting mistake that had devastating consequences—the patient immediately went into anaphylactic shock and suffered irreversible brain damage. At the trial, the court found the admission nurse guilty of negligence in a case of avoidable patient death.   

Asking the right questions is only half the battle. In the end, what matters is that all relevant information ends up recorded in enough detail for subsequent hospital personnel to be able to pick up and rely on throughout the entire course of treatment. Take extra initiative to notify other staff members on rotation, make sure the information is on their identification bracelet, and comply with hospital policies in place surrounding EHR procedures. It only takes one charting mistake to put lives and licenses at risk, so everyone needs to be on the same page. 
 

2. Failing to document prior treatment events 

It is essential to record every detail of a patient’s treatment, especially when treating multiple patients and across shifts. Individual patient developments can seem inconsequential in isolation, but even small errors can compound on themselves the longer an oversight persists. 

Take a patient coming out of surgery, for example. The day nurse observes heavy drainage from a surgical wound and changes the patient’s dressing. However, the day nurse forgets to record both the dressing change and the heavy drainage before leaving at the end of his shift. Later, the evening nurse also notices heavy drainage from the wound and checks the previous nurse’s notes for any indication of a prior dressing change.  

Because the day nurse did not leave any notes indicating the patient’s course of recovery, however, the evening nurse considers the amount of drainage normal for a period of several hours. She too changes the patients dressing but then also omits the bandage change in the chart. 

This pattern continues throughout the next day, each nurse leaving the next no indication of concern for the patient’s wound. Is the condition getting more serious? Is the patient’s life in jeopardy? No one knows because no one realizes that the patient’s wound is seeping more than it should. 

The most common excuse for omissions or holes in charting information is a lack of time to record everything thoroughly. And while it’s true that healthcare work is often highly demanding on time, that doesn’t mean nurses have to compromise on quality to get everything done—there have been plenty of helpful tools and strategies developed by people facing these exact same problems over the years. One efficient practice involves flow sheets that can be included in the patient EHR at the end of a shift. Leverage hospital standard flow sheets whenever possible, and ask where to find them in the HER system if you can’t locate them easily. 
 

3. Failing to record that medications have been administered 

Lifesaving drugs can all too quickly become life-threatening when administered improperly—either through overdose or adverse interactions. As such, it is central to record every medication given to the patient over the entire course of treatment—including the dose, route, and time of each administration. 

A day nurse once gave a patient heparin by intravenous push just before she went off duty. An hour later, the evening nurse saw that an order had been placed for heparin—but no indication that the medication had already been given. The evening nurse then proceeded administer the full dose once again, causing the patient to hemorrhage to the point of hypovolemic shock. Fortunately the patient survived the ordeal, but he went on to successfully sue the hospital for malpractice in administering an entirely avoidable overdose. 

Both nurses made mistakes in this situation. The day nurse should have recorded that the patient had received his medication, but the evening nurse also should have been suspicious of the heparin order with no indication that the dose had been administered. In this scenario the nurse could have protected both the patient and the hospital by taking a few simple steps to mitigate risk to the patient. Asking the patient if they have received their medication, confirming with the hospital pharmacy about whether or not the medication had been furnished, or even reaching out the previous nurse directly all could have prevented the more perilous error and the lawsuit that followed it.  

As a rule of thumb, nurses should avoid making assumptions when they notice gaps or missing information in a patient’s treatment documentation. Healthcare professionals have exceedingly demanding schedules, but it’s always better to take the time and double-check the details than to make assumptions and be wrong. 
 

4. Recording on the wrong patient’s chart 

Given the sheer volume of patients the average hospital commonly treats at a time, there are any number of ways one patient might confused with another—an honest mistake with potentially dire consequences. As such, nurses really can’t be too careful in 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.  

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 far more costly than the time required to double-check the name on the sheet. 

When there are two or more patients with the same name, be sure a different nurse is assigned to each patient; develop a system of flagging the patients’ names and medication records. And always double-check wristbands before giving medications. 
  

5. Failing to document discontinuation of a medication 

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. 

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’s 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. Adopting the simple practice of cross-checking doctors’ orders and medication sheets can prevent mistakes likes these. 
 

6. Failing to record drug reactions or changes in the patient’s condition 

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. 

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 over the course of their career, 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. 

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. 
 

7. Transcribing orders improperly or transcribing improper orders 

Patients’ nurses are responsible for familiarizing themselves with a patient’s medications, procedures, and activities as well as documenting ongoing developments in treatment for the reference of others. A great responsibility indeed, and with it comes liability. If transcribing orders on the wrong chart or transcribing the wrong dose, nurses can be held liable for any resulting injury. Nurses can also be held liable 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 take it upon themselves to understand the details of their patient’s treatment well enough to recognize when something isn’t right.  

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, although she had been suspicious 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.  

Medication errors like this are among the most common in the entire healthcare industry. So if at all suspicious that a mistake or miscommunication has occurred somewhere in patient’s treatment or prescribing information that could put them at risk, absolutely do not hesitate to reach out and double-check.   
 

Conclusion 

It’s natural in healthcare settings to feel like there aren’t enough hours in the day to tick every box and triple-check every detail, but careful attention to thorough charting practices is never a waste of time. Details save lives, and consistently getting them right is what makes people feel safe when they go to the doctor. Moreover, it’s also what keeps nurses from having to defend their actions in a courtroom someday. Understanding these realities can add hours to the day, so the practical approach is to be strategic with efforts. Look for efficiencies, work with colleagues, and use best judgment and ingenuity to find ways to get everything done while still doing it right. It’s not easy, but it’s also not impossible. By remaining cognizant of the pitfalls outlined above and marshalling talents to ensure against them, nurses can become better at doing what they all got into medicine to do: help people and do no harm. 
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