Among the many details that make up your day, perhaps charting is one of the most time-consuming and tedious. Even though you may dread the task, you know how important it is to keep up with the load. Whether your department has the latest computer programs for patient records or you are still using pen and paper, charting is an essential line of communication between you and others on your team.
Charting mistakes and fraud can lead to disciplinary actions, placing your career at risk. While fraud is intentionally misrepresenting the facts, mistakes are far more common. Nevertheless, if your charting mistake leads to patient injury, you may have to deal with the legal consequences.
Common chart omissions
There is no question that a nurse’s job is stressful. You may deal with life-and-death decisions daily, and your patients depend on your level-headed thinking. Time is precious, and charting may slow you down and prevent you from moving quickly to the next patient who needs you.
Nevertheless, when it comes to charting the events in a patient’s care, you know the importance of thoroughness and attention to detail. If you are facing disciplinary action for any of the following charting errors, you are not alone. These are among the most common items nurses forget to include on patient records:
- Allergies to drugs or foods
- Preexisting conditions or diseases, such as hemophilia, that can affect the choices in patient care
- Actions you perform on a patient, such as changing a dressing or checking a wound
- Administration of medication or clarification of a previous dose
- Doctor’s orders for the discontinuation of a medicine that is causing adverse effects in a patient
- Reactions to medications or changes in the condition of the patient
While it is understandable that you may be rushing to get to your next patient, charting is so critical to patient care that your diligence and focus can literally mean the difference between life and death for a patient. It is not uncommon for a nurse in a hurry to record information on the wrong patient’s chart, transcribe numbers or move a decimal point in a medication order with lethal results.
Facing disciplinary action for a charting error can be terrifying, especially if the mistake resulted in patient injury. You will likely have many questions and concerns about the best way to proceed to protect your nursing license and your future. Fortunately, there are legal professionals dedicated to defending nurses dealing with the Pennsylvania State Board of Nursing.