8 Common Charting Mistakes to Avoid

[amy0123, BSN, RN]

i was given advise from a nurse who told me if you discharge a pt quickly, you don't need to document it. this brought up a red flag, and i had came across the nso website with oodles of information about documentation. i would like to pin this to my unit's bathroom door and show this to the nurse i spoke to because this is important info.

8 common charting mistakes to avoid

recording information in your patient's chart is an important part of your job as a nurse. there are many ways that charting mistakes can be made. by making yourself more aware of these eight common pitfalls, you can not only avoid making these mistakes but you can also avoid being involved in a lawsuit.

1. failing to record pertinent health or drug information

2. failing to record nursing actions

3. failing to record that medications have been given

4. recording on the wrong chart

5. failing to document a discontinued medication

6. failing to record drug reactions or changes in the patient's condition

7. transcribing orders improperly or transcribing improper orders

8. writing illegible or incomplete records

___________________________________________

read information specific for each item 1 - 8:

8 common charting mistakes to avoid

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[bigsyis]

I am amazed that the nurse that told you that is still employed. Anywhere I've ever worked documentation is reviewed for quality and accuracy, from time to time. Any time you do anything for a pt it needs to be recorded somewhere. Good for you for not taking what she said as the truth!

[amy0123, BSN, RN]

She has 20+ years of experience under her belt. And the advice given to me by her didn't make me feel very safe about documenting. I had gone to Barnes & Nobles, combing through the shelves for a book about nursing documentation. Most books are so general with no real examples. But this website has really brought up my confidence and knowledge in the importance of charting! It definitely answered my questions!

Maybe there should be an inservice done on this topic for my unit. I would like to talk to my nurse manager about educating the staff. Most of the staff are new nurses too...

[pagandeva2000, LPN]

Great information. Thanks for sharing.

[EmmaG, RN]

I was given advise from a nurse who told me if you discharge a pt quickly, you don't need to document it.

That makes no sense. Did you ask her to clarify that statement?

[Diary/Dairy, RN]

Great information - thanks for bringing it up....

[amy0123, BSN, RN]

That makes no sense. Did you ask her to clarify that statement?

I did question her, she said "it would save time", it was "insignificant and assessments need to be complete" for quite a few surgical admissions that had followed after the discharge. I got the impression that there is no time for charting so whatever is least priority in charting, let it go.

I realized what she said, and needed resources to confirm my conviction about documention. I see nurses rushing through charting to get home on time, and sometimes they stay over an hour or more to complete documenting, especially if the pt had nearly coded or if they had multiple interruptions throughout the shift and were unable to chart at all.

[BGgirl]

Great information.

I find that the nurses on my floor are especially horrible at documentation. We've had such a problem that now when we receive critical lab values, whoever takes the lab value must record it on a special sticker with info such as the pts name, mr #, lab value, md notified, action taken etc. This then goes into the physician progress notes because either stuff was getting missed or you couldn't even tell if a physician was notified of a critical lab value because of the lack of charting.

I mean you need to cover yourself legally so I try and document as much as I can with each pt if something significant happens.

[TheCommuter, BSN, RN]

Also, do not document that "Staff will continue to monitor" unless the patient is actually on real monitors. A nurse who works in the facility's legal department told me this tidbit. Better wording for the same situation would be "Staff will continue to observe," or "Staff will continue to provide observation."

[BGgirl]

Also, do not document that "Staff will continue to monitor" unless the patient is actually on real monitors. A nurse who works in the facility's legal department told me this tidbit. Better wording for the same situation would be "Staff will continue to observe," or "Staff will continue to provide observation."

I use continue to monitor all the time in my charting. Thankfully our pts are all on telemetry but I never knew that. Interesting.

[amy0123, BSN, RN]

Also, do not document that "Staff will continue to monitor" unless the patient is actually on real monitors. A nurse who works in the facility's legal department told me this tidbit. Better wording for the same situation would be "Staff will continue to observe," or "Staff will continue to provide observation."

Great tip! Thanks!

From reading other documentation, I usually see at the end of a note "safety and comfort maintained" or "continue to monitor" (There's no monitors on the unit)

[BeaconRN]

She has 20+ years of experience under her belt. And the advice given to me by her didn't make me feel very safe about documenting. I had gone to Barnes & Nobles, combing through the shelves for a book about nursing documentation. Most books are so general with no real examples. But this website has really brought up my confidence and knowledge in the importance of charting! It definitely answered my questions!

Maybe there should be an inservice done on this topic for my unit. I would like to talk to my nurse manager about educating the staff. Most of the staff are new nurses too...

Hello

I am also a new grad in a Med/Surg unit, and I am VERY glad my Preceptor is all about document!! document!!!& document!!! "care not documented is care not done". I have tried to "chart" as much as I can about my pts, we also document by exception. Like you, I was looking for a good book about documentation, I found "Documentation in Action" by Lippincott Williams & Wilkins ed 2006, I dont know if there is a newest edition. It is great book, it has a LOT of examples, notes & charts. It provides you with examples of daily documentation (basic skill) as for what to document during different challenging conditions. It also focuses on the legal & ethical implications of documentation as we know. It has hundreds of written nurses's notes that provide a model for your own notes. Well, just to let you know, I am going to look if there is a new edition. Good luck to you...