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8 Common Charting Mistakes To Avoid

Heres advice that can help keep your charting at its best--and keep you out of legal trouble.

Ive seen the kinds of charting mistakes nurses make most often. Review the eight Ive listed here so that

you can avoid them and the lawsuits they may lead to.

1. Failing to record pertinent health or drug information

Suppose the patient has an allergy or a disease (such as diabetes, hemophilia, or glaucoma) that his

caregivers need to know about. But you forget to record that on his chart. You could end up in court, as

did a nurse at a large metropolitan hospital.

The nurse neglected to record her patients penicillin allergy in the admission notes. Because the intern

didnt know the patient was penicillin-allergic, he gave the patient a penicillin injection. The patient, who

was incoherent and couldnt tell the intern about the allergy, went into anaphylactic shock and suffered

irreversible brain damage. At the trial, the court found the nurse guilty of negligence.

So you make sure you ask about every patients food and drug allergies, diseases, and chronic health

problems. And record the information on the admission sheet and in the nurses notes. Alert other staff

members to drug allergies by putting a bright label on the outside of the patients chart, according to

hospital policy.

2. Failing to record nursing actions

Record everything you do for a patient on his chart as soon as possible.

Lets say the day nurse observes heavy drainage from a surgical wound and changes the patients

dressing. But she forgets to record the dressing change and her assessment of heavy drainage before she

leaves.

The evening nurse also notices heavy drainage from the wound. She checks the nurses notes and finds no

evidence that the dressing was changed. She considers the amount of drainage normal for a period of

several hours. She changes the dressing but, like the day nurse, forgets to chart her action.

The night nurse does the same. Is the condition getting more serious? Is the patients life in jeopardy? No

one knows because no one realizes that the patients wound is seeping more than it should.

The usual excuse for not charting is "not enough time." Consider flow sheets that you can insert in the

patients chart at the end of the shift. If your hospital has standard flow sheets, use them. If it doesnt, ask

for them.

3. Failing to record that medications have been given

Record every medication you give when its given--including the dose, route, and time.

A day nurse gave a patient heparin by intravenous push just before she went off duty. An hour later, the

evening nurse saw the order for heparin--but no indication that it had been given. So she gave the patient

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the same dose. The patient began to hemorrhage and went into hypovolemic shock. He recovered--then

successfully sued the hospital.

Both nurses made mistakes here. The first should have recorded that shes given the dose. The second

should have been suspicious when she saw the order for heparin but no evidence that it had been given.

She could have:

asked the patient if hed received the medication.

called the pharmacy to see if the dose had already been furnished.

called the first nurse at home.

So always investigate when you suspect a medication may have been given but not recorded.

4. Recording on the wrong chart

You cant be too careful in any situation that might lead to confusion between two patients: same last

name, same room, same condition, or same doctor.

Mrs. B. Moyer and Mrs. C. Moyer were on the same unit. Mrs. B. Moyer was being treated for severe

hypertension; Mrs. C. Moyer, for acute thrombophlebitis. Mrs. C. Moyers doctor ordered 4,000 units of

heparin for her.

The nurse mistakenly transcribed the heparin order onto Mrs. B. Moyers chart and administered the

heparin. Mrs. B. Moyer started bleeding.

When you have two or more patients with the same name, be sure a different nurse is assigned to eachpatient; develop a system of flagging the patients names on charts and medication records. And check

wristbands before you give medications.

5. Failing to document a discontinued medication

If the patient is supposed to be taken off a medication because of its adverse effects, you need to

document that order promptly.

A doctor suspected that his patient, who was taking high doses of aspirin for arthritis, had developed anulcer. So he discontinued the medication. But the patients nurse forgot to record the order on the

medication sheet, and she and the other nurses continued giving aspirin. The ulcer bled, and the patient

eventually underwent a partial gastrectomy because her condition deteriorated. She sued the hospital for

the nurses negligence and won.

Cross-checking the doctors orders and the medication sheet before giving the medication would haveprevented this patients serious complication.

6. Failing to record drug reactions or changes in the patients condition

Monitoring a patients response to treatment isnt enough. You need to recognize an adverse reaction or a

worsening of the patients condition, then intervene before the patient is seriously harmed.

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A patient complained of nausea, dizziness, abdominal pain, and itchy skin shortly after receiving his first

100-mg dose of nitrofurantoin macrocrystals (Macrodantin). His nurse wasnt concerned, though. By

evening, after two more doses of the medication, he was vomiting and had a high fever, urticaria, and

early symptoms of shock. He sued his nurse for negligence.

The fact that most patients dont have adverse reactions to certain drugs shouldnt lull you into

carelessness; most drugs can cause problems in some patients who take them. So observe your patientsclosely, consider the possibility of adverse reactions when a patient reports new symptoms, and follow up

appropriately.

7. Transcribing orders improperly or transcribing improper orders

If you transcribe orders on the wrong chart or transcribe the wrong dose, you can be held liable for any

resulting injury. You can also be held liable if you transcribe or carry out an order as its written if you

know or suspect the order is wrong. And youshouldbe familiar enough with the medications, procedures,

and activities youre responsible for to know when something isnt right.

A doctor ordered 5 ml of atropine for a patient on the coronary care unit. He meant to order 0.5 ml, but

he didnt include the zero or write the decimal point clearly. The nurse transcribed the order as 5 ml,

although she didnt think it seemed right. She decided the doctor knew best and didnt check the dose

before recording it.

Anytime youre unsure about a drug order, check it with the prescribing doctor. And if youre sure the

order is wrong, tell the doctor why you cant administer the drug, then notify your nurse-manager. Shellprobably talk with the doctor and tell him that hell have to give the drug himself.

8. Writing illegible or incomplete records

These mistakes rarely cause lawsuits. But they can rear their ugly heads in the midst of lawsuits. Imagine

your embarrassment at being called to testify and not being able to read your own handwriting or havingto admit that the information recorded is incomplete.

To play it safe, remember each of these good charting practices:

Print if your handwriting is difficult to read.

Sign your full name and title somewhere on every page where youve charted.

Dont leave blank spaces, lines, or boxes on charts. If you dont use the space, draw a line

through it or write N/A (not applicable).

Dont use abbreviations that arent on the hospitals approved list of abbreviations. Chances are

someone could misunderstand your abbreviation. And years later, you may not even rememberwhat it meant.

Record every nursing action as soon as possible after youve finished it.

Write enough to convince a reader that the patient was adequately cared for.

Such careful attention to charting is never a waste of time. It helps you demonstrate the good care youve

given, saving yourself the need to defend it in court someday.

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