Nurses have an enormous responsibility to patients when it comes to charting. According to HCPro, problems with documentation can result in lost revenue, poor quality care, fraudulent billing and the loss of a license.
The nurses service organization points out that including inaccuracies in charts could also result in patient deaths. When there is harm to a patient, without a record of their actions, nurses may not be able to defend themselves if a malpractice case goes to court.
Here are a few of the most common charting mistakes.
Leaving out information
Failing to make a note of an allergy or a current medication could result in personal liability for nurses. In addition to gathering and recording this type of information, administered medications and other actions must be available to the next health care professional who cares for the patient. It is not enough to do everything right if there is no documentation of the actions.
Recording information on the wrong chart
This may seem like an extreme oversight, but nurses may have many patients at once. There may be patients with similar or even the same name, patients with similar conditions and other confusing factors.
When such issues arise, providers should find ways to keep the confusion to a minimum. For example, they may assign two patients with the same name to two separate nurses so that one nurse is not providing care to both. Even so, nurses should always check the name on the sheet and the name on the patient identification band, and double-check the medical records every time.
Transcribing improper orders
Sometimes, a doctor’s orders may seem suspect. When an order appears to have a mistake in it, a nurse may become liable if he or she does not check with the doctor to see if there is a simple but possibly devastating error such as a missing decimal point.