I charted that he died!

[mgababyko]

We do computerized charting and my boss called my attention about an entry I made that said the patient DIED. I charted on the wrong patient! I could not correct it because it happened 2 weeks ago. We can only edit within 24 hours. I know the entry would be permanent on the patient's record. What can I do about it? I realized one factor was that I had 2 pt's w/ the same first name.

[handyrn]

Can't you just go in and do an ammendment entry stating that the entry on such and such date was not intended for this chart? Obviously, people have to be charting on this person and know this was a mistake, all you should have to do is make an entry to explain your mistake.

[SuesquatchRN, BSN, RN]

This is a questions for your computer folks, mgababyko.

[november17, ASN, RN]

I had one of my coworkers, an experienced nurse of 25+ years, chart all day on 1 patient as if it was another. She charted all kinds of crazy stuff!!! She had to chart a ton of crossouts, explanations, and addendums to the charting she had done (including recharting everything into the proper charts). It is funny in retrospect, and yea it was a permanent part of the record, but at the same time who the heck really looks at that stuff anyways? It goes down to the deep dungeon of medical records...it's not like the patient scrapbooks it or something

[GilaRRT]

I had one of my coworkers, an experienced nurse of 25+ years, chart all day on 1 patient as if it was another. She charted all kinds of crazy stuff!!! She had to chart a ton of crossouts, explanations, and addendums to the charting she had done (including recharting everything into the proper charts). It is funny in retrospect, and yea it was a permanent part of the record, but at the same time who the heck really looks at that stuff anyways? It goes down to the deep dungeon of medical records...it's not like the patient scrapbooks it or something

Not until the patient and their legal team start hitting people up for money, then the chart becomes a bit more important.

[RNgirlie]

i would just made a not in the patients chart right away stating that on such and such date at such and such time a wrong entry was made mistakenly. "information placed was mistakenly entered in the wrong electronic chart."

u should be fine. we all have mistakenly entered info on the wrong pt before at some point. it just has to be amended.

[Christie RN2006]

I screwed up on the charting of one of my patients a few weeks ago. All I had to do was view the old chart through medical records and make my corrections on paper and submit it to be added to the chart as a correction for the error I made. Check with your NM to find out how to go about correcting it.

[pagandeva2000, LPN]

Usually, there is an area in electronic charting (at least in the Medsys system we use) where you can cancel your note and choose from multiple keys that explain why it was canceled. For us, one of them is actually "charted on wrong patient". As long as you were the one that did it, you can correct, supplement, subtract or cancel your note. Of course, the original is in cyberspace, but, you can also free text an addendum of what actually happened if you wish.

[TiredMD]

"Charted on the wrong patient"? Sounds like a great way to get in trouble.

I would have gone with "clicked wrong box".

[TazziRN, RN]

"Charted on the wrong patient"? Sounds like a great way to get in trouble.

I would have gone with "clicked wrong box".

EVERYONE, every single one of us, at one time or another, has made an entry on the wrong chart. It's perfectly acceptable to cross out an entry and write "Wrong patient" or "wrong chart" and initial it.

[meownsmile, BSN, RN]

We can go in and ammend or change our charting fairly easily. Everything is ammened with incorrect entry, is striken and we rechart an accurate corrected entry.

[pagandeva2000, LPN]

"Charted on the wrong patient"? Sounds like a great way to get in trouble.

I would have gone with "clicked wrong box".

That is the most accurate option available in this case, and it would be true. There are about 10 other selections to choose from, such as duplicate entry, supplement, and such. I don't see anything wrong with it, especially in the case of accidently saying that the patient died, and you have to report vitals and pick up medication orders the next morning.