Chart A Course Away From The Courtroom By Proper Medical Recording
From the time nurses hit the hospital floor for their shift
, they are constantly in motion-caring for patients and supporting the physicians. Creating entries in patients' charts is a task that is central to the job, and recording the information properly is extremely important-not only for the sake of the patients, but for the sake of the medical staff. Unfortunately, errors and omissions by medical professionals can and do happen. For example, there fact, there are a variety of common charting mistakes that occur in hospitals. Nurses should be aware of these mistakes and avoid making them, or they may find themselves involved in a lawsuit.
Mistake: Not recording drug and health information
Recording food allergies, drug allergies, or an existing disease is vital to those who will prescribe a course of treatment for the patient. Forgetting to record this information can put the patient at serious risk, and make the nurse open to a lawsuit.
Mistake: Not recording observations and activity
Observations of patients' behavior and the actions the nurses take as a result should be charted in a timely fashion before memories get hazy. This also helps ensure that nurses working the next shift can determine whether observations are continued behavior that started hours earlier, or a new development.
Mistake: Putting the right information on the wrong chart
It's easy to confuse patients with similar-sounding names, or patients who are in the same room, or who have the same illness or are being treated by the same physician. Before making a chart entry, compare the chart and the patient's wristband to ensure they match.
Mistake: Not recording a medication that has been discontinued
It's extremely important to immediately chart the event when a patient's medication has been discontinued. Again, failing to chart this critical data could result in harm to the patient, and leave the nurse open to a
lawsuit.
Mistake: Not recording drug reactions or changes in the condition of the patient
Nurses don't just monitor patients, they should also be able to spot a patient's worsening condition, or when he or she is having an adverse reaction to drugs, and react accordingly.
Mistake: Not transcribing orders correctly
A nurse can be held liable for injuries that are the result of him or her transcribing orders onto the wrong patient's chart, or inaccurately transcribing orders. What's more, the nurse could also be held liable if he or she transcribes or executes an order exactly as it is written without question, despite thinking or knowing that the order is incorrect.
Mistake: Incomplete or impossible-to-read entries
Experts say that illegible entries in and of themselves may not be a frequent cause of lawsuits, but if a suit does occur, chart entries that are impossible to read can strengthen the plaintiff's charges of an insufficient level of care.
Considering how
errors and omissions by medical professionals can occur when charting, it's important to approach this task with the considerable attention to detail it deserves. Complete and thoughtful charting can make all the difference in keeping a potential lawsuit from turning into an actual one.
by: James A. Laduke
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