There are several types of documentation mistakes other than omission. Several are"
Documenting a concerning finding but not documenting a conversation with the physician.
Writing- will monitor with no follow up note
Conflicting documentation- one nurse charts edema and another on the next shift charts none with no explanation
Overdelegation or inappropriate delagation of assessments becomes evident in nursing documentation
Computer charting - just filling in the blanks is not enough information to adequately communicate findings to other members of the team
- are living and breathing documents that need to be taylored to individual patient needs. Care Tracks not completed or unchanged is a clue to short staffing and not modifying care as needed. Care Planning is the primary method by which nurses document the nursing process.