Healthcare Professionals can help reduce the risk of medical-related accidents and deaths, as well as lessen the chances of facing liability litigation, through proper charting and documentation. The following mistakes and strategies should aid in keeping accurate medical records.
Deaths due to medical errors remain one of the most common causes of fatality in the United States. A 2016 study by Johns Hopkins University found that more than 250,000 people in the U.S. die each year as a result of medical errors. For nurses and any other healthcare provider, the occurrence of a medical error is likely to be revealed in the charting and documentation related to each patient’s delivery of care. Whether that proof be evident in the omission of a pertinent detail or be seen in the negligence of an incorrect notation, the documentation recorded for patients can go a long way in determining liability in the instance of an adverse patient event.
With the advancement of technology, today’s nurses have the ability to record their patients’ charts and documentation through the use of digital platforms that are purported to make recordkeeping more easily accomplished. But these same advancements can also create a dynamic in which providers are more likely to commit errors if information is not carefully crafted and entered. What follows is a series of generalized, common mistakes for nurses to be mindful of when compiling documentation, as shared by David Griffiths, senior vice president of the Nurses Service Organization (NSO), Hatboro, PA, for nurses to consider to help reduce their likelihood of a medication error. Strategies are also shared.
1. Failing to record pertinent health or drug information
A patient’s health record is the significant point of reference for any provider to communicate to another that a particular patient lives with an allergy or a disease that his caregivers will need to know about. Failure to include this type of information on the chart could result in the nurse being accused of negligence, Griffiths said. Griffiths also said that nurses should always ask about every patient’s food and drug allergies, diseases, and chronic health problems. A documented record of this type of information on the admission sheet and in the nurses’ notes is essential. Nurses can also alert other staff members to drug allergies by putting labels on the patient’s chart, in accordance to hospital policy, he said.
2. Failing to record nursing actions
“Record everything you do for a patient on his chart as soon as possible,” Griffiths said. “The usual excuse for not charting [among nurses] is ‘not enough time.’” In an effort to help streamline information, Griffiths suggests that nurses consider flow sheets that can be inserted in the patient’s chart at the end of each shift to be reviewed and used as a starting point for each staff member throughout the day and evening.
3. Failing to record that medications have been given
Nurses should record every medication given to a patient when it’s administered, including the dose, route, and time. In the event that a nurse believes that a patient is displaying symptoms of having received a medication that has not been documented, Griffiths suggests that the nurse who’s currently in possession of the documentation inquire about any possible medication administration with current staff.
4. Recording on the wrong chart
Any of us would be hard pressed to find anyone in any profession who hasn’t made mistakes during their day-to-day job duties. But when a mistake is part of a permanent record, that’s a line of demarcation that can’t be avoided when it comes to liability. Patients as a whole will frequently share a combination of the same last name, same room, same condition, or same doctor, and nurses must be careful that charts do not become convoluted.
“You can’t be too careful in any situation that might lead to confusion between two patients,” Griffiths said. “When you have 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 on charts and medication records,” Griffiths said. “And check wristbands before you give medications.”
5. Failing to document a discontinued medication
If a patient is supposed to be taken off a medication because of its adverse effects, a documented order must be made promptly. As an example, Griffiths cites an unnamed doctor who suspected that his patient, who was taking high doses of aspirin for arthritis, had developed an ulcer.
“So [the physician] discontinued the medication, but the patient’s nurse forgot to record the order on the medication sheet, and she and the other nurses continued giving aspirin,” Griffiths said. “The ulcer bled, and the patient eventually underwent a partial gastrectomy because her condition deteriorated. She sued the hospital for the nurses’ negligence and won.”
This serious complication could have been prevented through a crosschecking of the doctor’s orders and the medication sheet before giving the medication would have prevented, Griffiths continued.
6. Failing to record drug reactions or changes in the patient’s condition
“Monitoring a patient’s response to treatment isn’t enough; you need to recognize an adverse reaction or a worsening of the patient’s condition, then intervene before the patient is seriously harmed,” Griffiths said, adding the fact that most patients don’t have adverse reactions to certain drugs and that shouldn’t lull a provider into carelessness.
“Most drugs can cause problems in some patients who take them,” Griffiths said. “So observe your patients closely, consider the possibility of adverse reactions when a patient reports new symptoms, and follow up with [a physician] appropriately.”
7. Transcribing orders improperly or transcribing improper orders
“If you transcribe orders on the wrong chart or transcribe the wrong dose, you can be held liable for any resulting injury,” Griffiths related. “You can also be held liable if you transcribe or carry out an order as it’s written, if you know or suspect the order is wrong. And you should be familiar enough with the medications, procedures, and activities you’re responsible for to know when something isn’t right.”
As an example, Griffiths discussed a doctor who ordered 5 ml of atropine for a patient on the coronary care unit who meant to order 0.5 ml, but he didn’t include the zero or write the decimal point clearly. The nurse transcribed the order as 5 ml, although she didn’t think it seemed right. She decided the doctor knew best and didn’t check the dose before recording it.
“Anytime you’re unsure about a drug order, check it with the prescribing doctor,” Griffiths said. “And if you’re sure the order is wrong, tell the doctor why you can’t administer the drug, then notify your nurse-manager. She’ll probably talk with the doctor and tell him that he’ll have to give the drug himself.”
8. Writing illegible or incomplete records
These mistakes rarely cause lawsuits, but they can enhance the possibility of a patient winning a liability claim against a nurse if other factors, Griffiths said.
These charting practices are also good guidance, according to Griffiths:
- Print handwriting if the print is difficult to read.
- Sign one’s full name and title somewhere on each page charted.
- Don’t leave blank spaces, lines, or boxes on charts. Unused space, draw a line through it or write “N/A” (not applicable).
- Don’t use abbreviations that aren’t on the hospital’s approved list of abbreviations. Chances are someone could misunderstand an abbreviation. And years later, the provider may not even remember what it meant.
- Record every nursing action as soon as possible after a task has been completed.
- Write enough to convince a reader that the patient was adequately cared for.