How to prevent documentation errors in nursing

As the primary point of contact for patients, nurses have a great deal of responsibility when it comes to documenting patient care. Nursing documentation is important for both practical and legal reasons.

Improper documentation can open up an employer to liability and malpractice lawsuits, while proper nursing documentation helps prevent medical errors and promotes the delivery of high-quality patient care.

Nursing Documentation Tips

The following tips, recommendations, and best practices can ensure your documentation is as precise and useful as possible.

Be Accurate.
Write down information accurately in real-time. Inaccurate or misleading documentation is unethical and can harm patients.

Avoid Late Entries.
Late entries can introduce inaccuracies. If you have to document something after the fact, follow your employer’s late entry policy and clearly mark late entry notations.

Prioritize Legibility.
Others must be able to read your documentation without difficulty. In addition, legible writing improves your credibility and authority.

Use the Right Tools.
Nursing documents can be used in legal proceedings. For that reason, use only blue or black ink and never erase information from a nursing document; make a correction and initial it instead.

Follow Policy on Abbreviations.
When you use abbreviations, be sure they’re standard for your employer. Don’t use obscure or colloquial abbreviations, which can be confusing to other people reading your documentation.

Document Physician Consultations.
Document all parties consulted during patient care, including names, times, responses, and any resulting actions. This is critical in case a need or emergency arises.

Chart the Symptom and the Treatment.
Make sure you document both the symptom and the treatment you administered to address it.

Avoid Opinions and Hearsay.
Don’t write down opinions as facts. Use quotation marks to indicate an opinion and attribute the remarks to the correct person.

Common Nursing Documentation Errors

Common errors to avoid in nursing documentation include the following.

Medication or Allergy Omission.
Knowing what medications patients are taking and what they’re allergic to is critical to a doctor’s ability to administer the right treatment.. If a patient complains of a symptom, and that symptom is a side effect of a medication interaction introduced because the patient’s medications weren’t documented properly, it’s that much harder to narrow down what’s causing the symptom. Specify each medication administered, any permissions required, dosages, and patient reactions. Similarly, knowing that a patient is allergic to penicillin can be the difference between treating a simple infection with the right drug and creating more medical issues for the patient.

Blank Items on a Chart.
Blank spaces on a chart do more than fail to provide necessary information; they also create ambiguity. Was a space left blank because treatment wasn’t administered or because the nurse forgot to document the treatment that was administered? Blank spaces on charts can have legal ramifications, too. A patient who sues has a much stronger case if treatment wasn’t documented, even if it was provided; there’s no way to prove the treatment occurred.

Unclear Orders.
Just as you should never write unclear documentation, you should never accept orders you have questions about. If you disagree with or don’t understand an order, seek clarification. It’s better to take the extra time to understand what a patient’s treatment should be. When documenting orders, leave out the guesswork; ensure that you are conveying information as clearly and precisely as possible.

Improving Your Nursing Skills

Nursing documentation is critical to effective communication within a patient care team. Develop the communication skills you need with an RN to BSN online from Rivier University. Students learn in a convenient and flexible online environment that accommodates their work and personal schedules.

Medical records form an important part of the management of a patient. It is important for doctors and medical entities to properly maintain the medical records of patients to analyze the treatment results, plan an appropriate treatment protocol, and avoid any legal consequences. Serious errors in medical records can lead to a breach in the duty of care to the patient, serious injuries, or some other form of negligence. Medical malpractice/negligence attorneys can utilize professional medical review solutions to review the injured patient’s medical chart and collect the medical evidence necessary to develop the case. Medical records may include a variety of documentation such as the patient’s history, clinical findings, diagnostic test results, treatment plans, preoperative care, operation notes, post operative care, patient’s progress notes and medications used.

Online patient portals enable patients and caregivers to access their health information. Patients may have the right to access certain records such as discharge summary, referral notes, and death summary in case of natural death. However, certain records may be issued only after the patient or authorized assistant fulfills the due requirements as fixed by the hospital and some records cannot be given to patients without the direction of the Court.

Common Medical Documentation Errors

• Incorrect diagnosis, scan or lab result
• Transcription error
• Wrong medication instructions
• Omissions in medical records
• Improper documentation of medication instructions in the EHR
• Entering orders in the wrong patient’s chart, mainly for patients sharing the same name
• Wrong demographic data such as patient’s name, address, phone number or personal contacts
• Using the wrong abbreviations
• Mistakes in the radiology report that could result in a wrong diagnosis

Record Documentation Errors Are Common

According to a report from Becker Hospital Review, about 70 percent of patient records have wrong information. While some errors don’t affect health outcomes, other can be dangerous or even fatal. A shocking report by Johns Hopkins study cited by CNBC found more than 250,000 people in the U.S. die every year from medical mistakes.

Another study published in Pub Med highlights that of the 22,889 surveyed patients who read their own records, 4830 (25%) found mistakes. Almost 10% were classified as very serious, 42.3% as serious, and 32.4% as somewhat serious. The most common type of error involved a current or previous diagnosis, wrong medical histories, errors describing medications or allergies, records listing informed consent or counseling discussions that patients said did not occur.

Improper documentation can –

• open up an employer to medical negligence and malpractice lawsuits
• compromise the patient’s ability to get insurance coverage
• raise the possibility of inappropriate medical evaluation or treatment
• researchers fail to conduct patient-related studies
• result in incorrect treatment decisions
• lead to expensive and unnecessary diagnostic studies
• result in unclear communication between consultants and referring physicians
• decrease reimbursement/gross revenue

Documentary evidence is crucial in case of a medical negligence. Insurers also require proper records to approve patient claims or medical expenses. Breach of confidentiality of the records also may lead to the patient claiming negligence against the hospital or the doctor.

Tips to Prevent Documentation Errors

• Patients’ medications, procedures, activities and ongoing developments in treatment need to be accurately documented for the reference of other caregivers.
• Never leave out even small details of the treatment given to the patient. All incidents that occurred and treatments provided should be documented, leaving no room for doubt regarding the patient’s condition.
• Dictate and sign operative notes within 24 hours of the operation/procedure, as this information in the chart is crucial for continuity of care when the patient is moved into the recovery room or discharged.
• Provide adequate training for your staff on proper documentation to avoid medical errors. Each patient’s condition and history of care should be recorded in a timely manner.
• To prevent wrong entries for patients with the same name, implement a system of identifying patients’ names and medication records.
• Meet the specific time requirements for completion of each element in the medical record. For instance, history and physical elements need to be completed and signed within 24 hours of admission, while post-op notes can be written immediately after surgery.
• Prescription for drugs should be legibly documented with the name of the patient, date, and the signature of the doctor.
• AHIMA recommends steps for a proper error correction procedure that involves striking through the wrong entry, making the inaccurate information legible, adding initial and date of the entry, stating the reason for the error and documenting the correct information.
• Providers should use EHR systems that have features to track corrections or changes once the entry has been entered or authenticated. Make sure that the original entry is viewable, enter the right date and time, and the identity of the person making the change and the reason behind.
• Design a form, either in paper or electronic version that patients can use to submit a suggested change.
• Establish procedures for documenting a late entry, if any information is missed or not written on time. Enter the current date and time on which the late entry is written. Validate the source of additional information as much as possible, to document an omission.
• Ensure an addendum to provide additional information is provided. Never use it to document information that was forgotten or written in error.
• Follow established time frames in which the omissions need to be completed. Use concurrent monitoring methods such as self-monitoring or shift-to-shift review to assure that the documentation is complete and timely for all medications and treatments administered.
• When documenting care provided by a colleague, place initials on the medication record.
• Physicians and hospitals are required to respond to the patient’s request for change as soon as possible.

Reliable medical review companies follow a comprehensive record review process when assisting lawyers and insurers in identifying the medical records relevant to the claim, any complications and adverse events in the medical course, and any missing medical records.

Disclaimer: The content in the above blog is sourced from reliable internet resources and is meant for informative purposes only. For a professional opinion on the same, please consult an experienced medical malpractice attorney.