Documentation Error

  1. I just graduated nursing school in Spring 2018. I started a job on a med/surg floor. I received orders over the phone to discharge my patient. I discharged my patient and realized a few days later I forgot to put in discharge orders before I discharged them. I'm so scared of losing my license!! Any thoughts??
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    12 Comments

  3. by   JKL33
    Contact your manager/director/supervisor and state, "I need some help with something I forgot to document." Tell him/her what happened in facts only just as you have written it here. No self-deprecation/drama.

    No sweat. It's okay. This shouldn't involve any sort of discipline whatsoever, even within your own unit/department.

    And....inquiring minds want to know (if we may, serious question): Where did you get the idea that someone would take your nursing license for this sort of thing?
  4. by   brownbook
    YOU WILL NOT LOSE YOUR LICENSE over a charting error.

    Call your unit manager and tell her what you "think" you might have forgotten to do. Ask her what you should do about it.
  5. by   nurseslrn
    In nursing school, ALL of the instructors stressed about when/how to write incident reports and ensuring you're being mindful in case you are called to court. They also stressed how you need to document correctly because in some cases you could lose your license. I'm a new nurse and maybe I'm just being paranoid?! Thank you so much for your reply, I work again Friday so I'll be sure to contact my manager!
  6. by   JKL33
    Thank you for answering. There is an ongoing discussion on the topic of losing one's license right now and it comes up every now and then.

    It's been suggested wisely that we all visit our state BON websites or google something like "[state] nursing license discipline" to get a better idea of the kinds of things that get people in serious hot water with boards of nursing.
  7. by   brownbook
    I just mentioned in another post that teachers were the cause of "lose my license" fears. Afterwards I honestly thought that I was making a wrong assumption's.. teachers aren't really telling students that.

    Sadly I guess I was wrong. They are teaching it!
  8. by   Pixie.RN
    Quote from JKL33
    It's been suggested wisely that we all visit our state BON websites or google something like "[state] nursing license discipline" to get a better idea of the kinds of things that get people in serious hot water with boards of nursing.
    Georgia is fun, we have the "imposter alert" page! Nursing - Imposter Alerts

    OP, it's going to be okay.
  9. by   Daisy4RN
    I would do as others have stated and just correct the error with your charge/manager. When you speak to your charge/manager I would also clarify the hospital policy as some facilities require the DC order to be placed by the MD (no phone/verbal orders), just so you know for next time.
  10. by   KelRN215
    This is a good example of why verbal orders are not best practice.

    Despite Technology, Verbal Orders Persist, Read Back is Not Widespread, and Errors Continue | Institute For Safe Medication Practices

    What kind of facility do you work in? Do you not have EMR? Does the MD not have to complete a discharge summary/discharge order form before a patient is discharged?

    This is not the kind of thing that nurses lose their license over. You should always document meticulously however the odds of your records being subpoenaed are fairly low. When the state took custody of a child in response to a report of neglect I filed years ago, they didn't even ask for my notes to present to the court.

    I agree with the others- look up the kinds of things nurses have lost their licenses for. This kind of discipline is public record. I know of 1 nurse whose license was revoked and it was for diverting narcotics and then failing to show up at any of her BoN hearings. I know of 1 MD whose license was threatened and she entered into a voluntary agreement not to practice and it was because she drank something like a liter of vodka while seeing patients one day.
  11. by   SC_RNDude
    Nursing instructors would lead us all to believe that nurses left and right are losing licenses, being sued, and testifying in court. In 8 years, I'm not aware of any of my coworkers having any of those things happening.

    I'm not saying those things don't happen, but they are rare.
  12. by   middleagednurse
    If every nurse who ever made an error lost their license, there wouldn't be any nurses left.
  13. by   Katillac
    I think instructors are aware that any nurse can be reported at any time to their board for anything. Whether the board will even investigate, never mind take any action at all or even less likely pull someone's license, is a whole different matter. I think instructors want new nurses to be mindful of the importance of following procedures and possible consequences of not doing so. But it's usually just that - possible consequences.

    Totally agree, though that this is something the OP should calmly and factually self-report and ask for her NM's guidance on, then let it go.
  14. by   Lorie Brown RN, MN, JD
    I believe that honesty is the best policy. When you make a mistake, it is better to deal with it up front rather than hide it. Boards appreciate this too. I suggest letting your manager know and asking for support on the best way to handle the situation. Make sure the documentation is noted as a late entry.

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