How To In-service Staff Who Did Wrong Med Documentation

MEDICAL ERRORS IN NURSING: PREVENTING DOCUMENTATION ERRORS

The importance of proper documentation in nursing cannot be overstated. Failure to certificate a patient'southward condition, medications administered, or anything else related to patient intendance tin can outcome in poor outcomes for patients, and liability issues for the facility, the doctor in charge, and the nurse(south). Let's await at an example.

A Case of Missing Documentation : InSusan Meek. 5. Southern Baptist Hospital of Florida, Inc. d/b/a Baptist Medical Center, the patient (plaintiff) was admitted to the hospital for a hysterectomy. She developed bleeding subsequently surgery and was admitted to the radiology unit for uterine avenue embolization (UAE) to finish the bleeding. Although the physician ordered the nurses to perform frequent leg examinations to mitigate the risk of diminished claret flow and nerve injury (a known complication of UAE), the patient claimed the exams were non performed, based on lack of documentation. The patient sustained nerve damage later on a massive clot was removed in the external iliac artery. The case resulted in a $ane.5 one thousand thousand verdict.¹

At that place is no way to know whether the nurse(s) responsible for the patient had in fact performed leg examinations, considering the supporting documentation was simply not in that location.

Nurses have a lot to fence with today-from electronic wellness records (EHRs) with page after page of forms and boxes to tick and fill in, to overcrowded conditions at healthcare facilities, to long and exhausting shifts. Environmental atmospheric condition, distractions, lack of training, infrastructural problems, and lack of communication can all lead to documentation errors. Nurses larn proper documentation procedures during their initial training, but nurse CE courses tin can provide important refreshers and updated information pertaining to documentation.

Alee we'll define what proper documentation is and why information technology's and so of import, explore common documentation errors, and look at some dos and don'ts of proper documentation.

DEFINING PROPER DOCUMENTATION AND ITS IMPORTANCE

Nurses are on the front lines of patient care. Their written accounts are critical for planning and evaluation of medical interventions and ongoing patient care. Nursing documentation must provide an accurate, complete, and honest account of the events that occurred and when. Adept documentation is:

Accurate
Factual
Complete
Timely (current)
Organized
Compliant with healthcare laws and facility standards

This applies to nursing documentation beyond every blazon of practice setting-from clinics, to hospitals, to nursing homes, to hospices.

Proper documentation serves many purposes for patients, physicians, nurses and other care providers, and families.

Thorough, accurate documentation is of import forcommunication and continuity of care-everyone involved in the delivery of care requires information most the patient.

Documentation is of import forquality balls-the information independent in patient charts is ofttimes used to evaluate the quality of service and the appropriateness of care delivered by nurses.

Proper documentation alsoestablishes professional accountability, demonstrating a nurse'due south knowledge and judgment skills, and it can help facilitiesassess funding and resource management.

Documentation is also very important forlegal reasons-patient records are oftentimes used as show in court.

ten Common DOCUMENTATION ERRORS

#ane: Not dating, timing, and signing entries

Every single entry should take the appointment, fourth dimension, and the proper name of the person who entered it. Unless y'all're working with an EHR/PMS that enters this data automatically, you must enter information technology every fourth dimension. On newspaper charts, indicate the engagement and time, forth with your first initial, full last proper name, and your title (RN, LPN, etc.). When your documentation continues from i page to the next, write your proper noun on each page, along with the date and time, and indicate "continued from previous page" on all subsequent pages.

#ii: Writing sloppily or illegibly

This requires little explanation. Sloppy writing tin result in confusion and communication problems that, at best, can atomic number 82 to inefficiencies and, at worst, could price patients their lives. Sloppy writing can also interfere with a nurse's defence in a malpractice suit.

#iii: Not documenting omitted medications or treatments

Medication and handling omissions happen, specially when your facility is curt staffed or when yous're pressed for time because you're working a double shift. Regardless of the circumstances, you are nevertheless accountable for these oversights. Always document omitted medications or treatments along with the reason for the omission and your signature.

#iv: Leaving blanks on forms

This leaves the reader wondering if care was delivered and not recorded, or non delivered at all, as in the legal case nosotros looked at before. Nurses need to describe a line through blanks that are not applicable on documentation forms, and initial them.

#five: Adding late entries

Anyone who has e'er tried to briefly memorize a phone number earlier dialing it knows that the information tin sideslip away within seconds. Failing to record actions taken and other information immediately or very soon after the event tin atomic number 82 to lost detail-especially when it comes to numbers-and ultimately errors down the line that could negatively impact the patient. Clearly land the date and fourth dimension of the belatedly entry, betoken the actual time the care or observation occurred, and marking it as "late entry."

#6: Documenting subjective information

Using terms like "demanding," "grumpy," and "irritating" to describe a patient reveals more most the nurse's attitude than the patient. In cases where the patient has a bad outcome, terms like these on a chart will call into question the kind of intendance the nurse provided.

#7: Using inappropriate abbreviations

Avert using abbreviations that can be misinterpreted, and result in confusion and errors. For case, using "D/C" for discharge can exist confused with discontinuing medications. Ever write "discharge." Avoid abbreviations that are not-medical, which can result in estimation errors.

#eight: Accepting incomprehensible orders

Never accept questionable or incomprehensible orders. If you don't understand the orders, or feel they are not in the all-time interest of the patient, question them every time. Remember that you are besides liable for patient outcomes, fifty-fifty when post-obit someone else's orders.

#9: Declining to document new symptoms or weather condition

You should certificate whatsoever new condition where advisable, including the time of occurrence, the activity you took, and the patient's response. This includes new abrasions, cuts, and pressure marks, falls, bumps, elevated temperatures, seizures, force per unit area ulcers, unusual behaviors, diarrhea, changes in bowel habits, changes in vital signs, etc.

#10: Entering data into the wrong chart

This fault tin can happen easily, especially with electronic records. Ultimately the problem occurs when a nurse isn't paying attention to the patient'south identity. Always accost your patient by name and ensure you lot accept correct electronic tape or chart in front of you before entering information.

DOCUMENTATION DOS AND DON'TS

Don't take shortcuts in electronic records systems, including copying and pasting medical records, which can lead to the carryover of inaccurate or outdated information. It takes more time, merely it's important to blazon out your notes every time.
Practise brand sure you lot're charting on the correct tape. With so many patients moving through a typical facility, information technology'southward easy to commencement documenting on the screen in front of yous, only to realize y'all're in the wrong patient's chart.
Don't delay documentation. It'southward as well easy to forget details if at that place is a delay between the time you took an action and recorded information technology. This can lead to a host of problems.
Don't document medications or treatments earlier they are administered or completed.
Practice use the patient's own words, gestures, and non-verbal cues every bit much as possible, which helps paint a movie of what you encountered.
Don't use vague terms, such as "fair" and "normal." Be clear, curtailed, and specific in your documentation.
Practice correct errors. Draw a straight line through incorrect entries, and write "fault" to a higher place them. Initial and engagement the correction. With electronic records, this may exist trickier-that's why it's important for facilities to have procedures in place for correcting entries. In general, you lot should brand a new entry along with the appointment and time. Indicate that you are correcting an mistake in a previous entry, and point clearly to that entry. The bottom line: It should be very obvious to readers which entry you are correcting.

STRANGE DOCUMENTATION ENTRIES

Nurse entries can be confusing, intriguing, and sometimes downright comical. Grammar and syntax issues are oftentimes at the heart of documentation bloopers. eHereConsider the following:

"Patient was alert and unresponsive." Was the patient alarm and unconscious simultaneously? Or maybe the patient was alert, but refused to or couldn't respond verbally to the nurse?

"Patient has chest pain if she lies on her left side for over a year." The message here seems to be that the patient has chest pain if she lies on her left side. She has experienced this for more a year.

"The skin was moist and dry." Huh?

"She is numb from her toes downwardly." What body function lies below the toes?

"The patient has done well without oxygen for the past year."At present, that's quite a talent.

These flubs illustrate perfectly the need for clear, curtailed documentation. Nurse educators should emphasize the importance of proper grammar and syntax in documentation, and instruct nurses to cross-check their notes with another healthcare professional person if they suspect their entry is unclear. Proper documentation techniques should be part of any registered nursing or certified nursing assistant training programme.