Few things can place your career and your nursing license in jeopardy as quickly as charting errors. Patient charts are a critical thread in the care and treatment your medical team provides, and your role in recording accurate and thorough information is essential. Errors and omissions can have devastating consequences, both for the patient and for all on the patient’s health care team.
Charting mistakes are different from falsifications. Intentionally misrepresenting the level of care you provide is fraud and may result in criminal consequences. Nevertheless, even the most innocent mistake on a patient record can become the crux of a medical malpractice lawsuit or a career-crippling disciplinary hearing.
Avoiding these common charting errors
Nursing is not an easy gig. You may have very few minutes during your day to stop and catch your breath. Whether you work in a hospital, clinic or private practice, you are likely understaffed and dealing with back-to-back patients most of the day. Stopping between patients to carefully chart your actions may seem impractical. However, many mistakes occur when nurses wait until the end of a shift or rush to record their actions or observations. Some of the most common mistakes include these:
- Forgetting to include relevant patient information, such as drug allergies, recent health issues or current medications
- Omitting important care you provided, such as changing a bandage or starting an IV
- Failing to chart medication you administered or to verify that someone administered a previous dose that was not recorded
- Failing to confirm that you are documenting on the correct patient’s chart, for example if patient names are similar
- Neglecting to note when a doctor discontinues or changes a patient’s medication
- Transcribing orders incorrectly or failing to question when a doctor’s orders do not seem appropriate, especially regarding medication dosage
An incomplete chart can leave you with little defense if authorities question you about a mistake in patient care. Your own careful charting and notations can provide evidence of a chain of care that may protect you and your career if your competence or quality of patient care is in question. It is worth the time and effort to chart immediately after interacting with a patient.
Nevertheless, if you are facing a disciplinary hearing or other consequences stemming from alleged mistakes in your charting, you would do well to seek advice from a California attorney who has extensive experience defending the licenses of medical professionals.