By March 22, 2010 1 Comments

Protect Yourself and Your Patients from Charting Errors

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I can’t imagine the level of attention to detail a traveling nurse must have, day in and day out. With little room for mistakes, a nurse must continually be alert and ready for action at any given notice and this is especially true since they are given little time to adapt to the new facilities during their various traveling assignments.  How you prepare and react to any given situation is a direct reflection of the type of nurse you may be. One determining factor on just how prepared a nurse may be is in how a nurse completes their charting and documentation.

Proper documentation can be all the differenceDocumentation is a very important part of a nurses duties and if you keep in mind the repercussions of a poorly documented case, you will probably change the way you approach charting and everything else revolving patient care. Ultimately you must keep in mind that what you write while documenting a patients care can end up in court as proof against you and the facility in question. In some instances it is foreseeable that you may have rushed through your notes or you were interrupted during the documentation process. These are somewhat excusable, but will it be in the court of law?

In the article, “Documentation-what were you thinking?” we are given a few examples of one nurses ACTUAL notes of how they documented their care. Not being a nurse myself, these examples are truly startling and left me to wonder just how a nurse can still have a job! Here are a few samples:

  • 1020: Patient to eosaphagramm????? (No idea what that means, and apparently neither did the nurse.)
  • 1220: Patient suddenly reappeared in room. (Was this patient a magician?)
  • 1005: Pt NPO per MD orders. Patient given PO meds with 120cc of water. Pt remains NPO. (Apparently NPO means to give orally, right?)
  • Patient given 2mg Morphine IVP through that beautiful foot IV. (Hmmm… I’m sure there are technical terms being missed here somewhere!)

What you see here is from one single nurse and sheds much light on the type of nurse they may be. Not one that I think I want taking care of me. The examples above are proof to the level of care that was provided and is a direct reflection of the nurse. To a lawyer and jury it will prove the levels of care were substandard and can be all they would need to prove you were a nurse incapable of providing the best possible patient care. Not what you want on your  permanent record.

In order to protect yourself from any legal battles or threats of termination I would recommend giving yourself the appropriate time to document the level of care you’ve provided for any patient in your care. A few extra minutes spent doing so can be all the difference in keeping yourself out of trouble, or worse yet, from losing your license and the job you love.

Here are a couple articles on ways to improve your charting process and how to protect yourself from errors.

Charting Smarter: Using new mechanisms to organize your paperwork.

Charting Defensively

5 for $500 Bonus

About the Author:

Patrick Fuerstenau here. Born in Kentucky, raised in Germany, landed in Nebraska and still here. I've been involved with Marketing and Advertising for over a decade. It all began with an internship at an ad agency in Omaha, followed by a 9 year stint as a graphic artist at the lone major newspaper in Omaha. A friend of mine told me about an opening at her company and said that it was the best gig she's ever had... So I decided to spread my proverbial wings and see what I could do for them and vice versa. So here I am at Medical Solutions and am going on my 3rd year as a Marketing Specialist for a great travel nursing company. This by far has been a major blessing in my life. I love the work I get to do just as much as I love the people who make up this fabulous company. I can see myself here for a long time... As long as they'll have me. Now that we've got the career timeline out of the way... Let me tell you a little about who I am. I am oh so passionate about the game of futbol! I've been playing soccer since the age of 8 and am still playing today. If I couldn't at least kick the ball around, I don't know what I would do with myself. I fear getting old. I also have a strong love for the arts... Music, Visual arts, Film, Design... pretty much anything and everything arty. I'm happy go lucky and am always looking to have a good time. Just ask my manager! And I love writing about travel nursing.

1 Comment on "Protect Yourself and Your Patients from Charting Errors"

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  1. Jennifer says:

    Patrick,

    I’m glad that someone is talking about this. I am not a nurse either but I hear charting horror stories weekly. I can’t tell you the number of RN clients our attorneys represent where the nurses’ license is under investigation and one of the disciplinable offenses the BRN can point to is a charting error.

    It’s important for RN’s to realize that charting errors aren’t just a big deal at work… they are a big enough deal they could be responsible for ELIMINATING YOUR ABILITY TO WORK all together. State regulatory nursing Boards are coming down hard, especially in CA. If you are a nurse thinking of traveling to CA… by all means come on over, but make sure you have a license defense program in place before you step off the plane! Look into RN Guardian for more info.

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