People are human, and they do make mistakes. But when it comes to nurses and their charting we simply cannot afford to have errors. One thing I always tell other nurses is to chart as though you have a judge and jury watching over your shoulder.
Nurses must be accurate when charting because we are dealing with human life, and even one charting error could cost someone dearly.
I remember when I was a student nurse, and I began learning how to chart. It seemed so foreign to me to be charting in what seemed like a different language, (medical terminology). The format that was necessary for other nurses and medical professionals to understand what you had written also seemed so strange.
I've been a nurse for over 25 years now, so I have a pretty good grasp on charting. But sometimes I almost think I know it so well that I run the risk of making errors because it's so second nature to me. Regardless of whether you've been a nurse for years, you're just starting your nursing career, or you're a nursing student, we all must be very alert when charting. We should also stay updated with commonly acceptable abbreviations, verbiage and terminology.
Some of the common abreviations that were around when I became a nurse are no longer acceptable. So change with the times nurses. You can't afford not to.
Keep in mind that while we all love overtime money, if you're fatigued and tired, you make mistakes. Just as the semi-truck driver pulls off the road when he's tired, to avoid an accident, nurses should not schedule themselves to work so many hours that they make mistakes from pure exhaustion. Sometimes we can't avoid working long hours, or not getting adequate sleep the night before. But it is possible to minimize your chances of making mistakes, because there are some common areas where they occur and being aware of them can make it easier for you to avoid them.
1. Failing to record pertinent health or drug history or information.
If unsure, chart it anyway. When a patient tells you something medically related, chart it. Even if you don't think it's that important now, it may come into play later, when the chart is viewed by the physician or other medical professionals.
It's important to realize that every piece of information in a patient's chart is like part of a puzzle. Those puzzle pieces may not mean anything by themselves, but combined with the other pieces of information can mean the difference between a correct diagnosis and an incorrect one. Also in charting, (and if I've said this once, I've said it a hundred times), if you don't chart it, it DID NOT HAPPEN. That's the way a court of law would see it.
You can claim you did X, Y, and Z all you want, but if it's not in the patient's chart, then you're wasting your breath, You've also opened yourself up for a law-suit.
I've heard nurses tell other nurses not to chart so much and that there is such a thing as over-charting. Don't listen to them. If it happened, chart it!
2. failing to record nursing actions
Never forget the importance of charting nursing actions. I've seen charts that explain everything in detail about the patient's condition, but nothing about what the nurse did about it. The attorneys will have a hay-day with this type of charting. Protect yourself by charting exactly what you did to treat the patient. Chart what the problem was and what your did about it.
3. failing to record what medications have been given
We've all seen this happen. It's lunch time, but right before going to the lounge to grab your frozen pizza, your call-bell goes off, and your patient needs pain medication. So you figure you'll give the medication, run on to lunch and chart when you return. Nothing wrong with that, right? Wrong. Inevitably you'll forget and it'll never get charted. Do yourself a favor and chart everything right away.
4. Recording on the wrong chart
This happens more than you'd think it does. Always check and double check to make sure you're in the correct patient's chart or file before you begin charting.
5. Failing to document a discontinued medication
If a medication is discontinued, it's very important to note that in the patient's chart, so other nurses know not to give that medication.
6. Failing to record drug reactions or changes in the patient's condition
If a patient has a reaction to a medication, it's essential to chart that information, so every medical professional that's dealing with that patient is aware of the reaction the patient had and the same thing doesn't happen twice.
If a patient's condition worsens, (or improves) chart it. These details are of the utmost importance to other medical personnel when they are assessing the patient.
It's important that you remember these common mistakes and try to avoid them. Nurses aren't perfect, but with charting it's imperative that we do our best to be as close to perfection as we can get.