Properly recording a patient’s chart is essential for all healthcare providers. Since nurses are typically around a patient more than any other healthcare provider, failure to properly record a patient’s chart can happen more frequently than with other healthcare providers. A patient’s chart is what helps other nurses maintain proper treatment of the patient and helps physicians make diagnoses based on changes with the patient. Our blog today discusses common nurse errors in patient charting. Errors in patient charting can range from noting the wrong patient’s chart to failing to document prior patient treatment events and many more that we will discuss below.
Recording Patient Health or Drug Information on Intake
One of the first things that should be recorded on a patient’s chart is what drugs a patient is currently taking and what the status of their health is. Are they short of breath? Does their chest hurt? If so, for how long? This information should be gathered upon check in of the patient to the healthcare facility. Proper intake is the first opportunity to help other healthcare providers diagnose and treat the patient. Failure to properly record patient health and/or drug information puts other providers at a disadvantage and potentially puts the patient in danger. Our next topic discusses the importance of properly recording patient checks and patient status in a hospital setting.
Error in Noting Status of Patient and When Last Patient Check Was Made
This type of error is one of the easiest to avoid. Hospitals will require that nurses check on their patients at certain time intervals. That can be every half hour, every hour, etc. The purpose is to ensure that the patient is comfortable and has everything they need, including properly working vital monitors.
If a patient check is made, not only does it need to be documented in the patient’s chart, but the status of the patient needs to be documented as well. This means the chart needs to reflect if the patient is fine or if a change in the patient’s condition has occurred. If a change in the patient’s condition has occurred, other nurses that will be attending to the patient will need that information in the future. Failing to note that the patient had fallen on the floor, for example, can cause major problems for the patient going forward. Other changes in the patient’s condition, which may seem minor at the time, may end up being very important.
It is also important to remember to record on a patient’s chart when you have finished a check, treatment, etc. for the patient. Waiting till the end of a shift is a risky way of documenting a patient’s chart. A nurse who does a ‘note dump’ may forget what has happened during the course of the shift. A nurse can also completely forget to do it after a long shift as well.
Noting the Wrong Patient’s Chart
A nurse can seemingly do everything right. He/she can make all their patient checks. They can record every treatment and medication administration as well as any events involving the patient, etc. However, noting the wrong patient’s chart can undo all the good work the nurse has done. Confirming the identity of patient, you are currently seeing can eliminate errors in medication and treatment administration as well as ensure you note the correct chart. Regardless as to whether or not the correct chart has been noted, failing to record discontinuation of a medication can result in a patient issue in the future.
Discontinuation of a Medication
As all nurses can probably attest, some patients are taken off medication for good reason . It could be that the medication is now causing harm to the patient. It could be that the diagnosis has changed, and the prescribed medication is no longer relevant to the patient. Whatever the reason, if a patient is to be taken off a medication, the patient’s chart should be properly recorded. If a patient’s chart is not properly noted, a nurse taking over care will not know to stop administering medication. Failure to discontinue medication that has been ordered discontinued can result in civil action as well as a license complaint.
Mistakes happen to all professionals, licensed or not. Licensed professionals have to be concerned with a number of factors though. This includes complaints from licensing boards. If you have an issue with the NC Board of Nursing or have a question, contact North State Law. The firm’s number is 919-521-8810. Also, please check out our other blogs here and our YouTube channel here.
Information provided here is for informational purposes only and is not legal advice. This blog and the providing of this information does not establish an attorney-client relationship with the reader.