Question regarding mistakes in documentation

[daniela095]

I am a new nurse on orientation. Today I had a patient in which I put some wrong things on the chart by accident from just pure not realizing at the time. I put that the diet was regular in my flowsheet when it was actually a DASH diet, and put that the patient was in desired limits regarding respiratory at the time of my assessment. She came in with shortness of breath but was fine at the time I assessed her. I realized after I already left. Has anyone else ever made stupid charting mistakes like this?

[Sour Lemon]

I am a new nurse on orientation. Today I had a patient in which I put some wrong things on the chart by accident from just pure not realizing at the time. I put that the diet was regular in my flowsheet when it was actually a DASH diet, and put that the patient was in desired limits regarding respiratory at the time of my assessment. She came in with shortness of breath but was fine at the time I assessed her. I realized after I already left. Has anyone else ever made stupid charting mistakes like this?

Yes, people make mistakes in their charting all of the time. I don't even know why diet is on the flow sheet. Orders should be referred to, for that.

I don't think charting WDL on a patient's respiratory status is a mistake if that's what you observed. 95% of the time, SOB is corrected before the patient comes from ED (although it may come back).