Please help this nursing student

[VenessaNesbitt]

If extensive test were performed on a patient and the patient info was entered in another patient chart, how is this corrected and what departments are involved. Please Help me.

[NightNurseRN13]

It depends on the system that is used and the facilities policy. I did that once while in school and we could do a soft delete meaning it was grayed out but still readable and then I just wrote a note attached to it explaining the mistake. Also told my instructor.

[NightNurseRN13]

Sorry, I just assumed that you were the one that put info on the wrong chart. Your best bet is to ask your instructor.

[ArrowRN, BSN, RN]

Is this reality or a seneario question OP? Cause if it is real you need to tell your instructor like yesterday, you are working on his/her license.

[VenessaNesbitt]

This was just a general question for a case study I'm working on. The patient was diagnosed with CHF. Extensive diagnostic test were done including radiology studies. It was later discovered that all the patient information was entered in another patient chart. What is the general protocols when this occurs and what departments will be involved.

So far I think the nurse should should make a report to her supervisor, and the doctors and both patients should be contacted and the information should be deleted from one chart and entered into the other. Should an incident report be written by the nurse. I know the billing department must be contacted, should the pharmacology and radiology department should also be contacted. So this was just a general question.

[VenessaNesbitt]

This was just a general question for a case study I'm working on. The patient was diagnosed with CHF. Extensive diagnostic test were done including radiology studies. It was later discovered that all the patient information was entered in another patient chart. What is the general protocols when this occurs and what departments will be involved.

So far I think the nurse should should make a report to her supervisor, and the doctors and both patients should be contacted and the information should be deleted from one chart and entered into the other. Should an incident report be written by the nurse. I know the billing department must be contacted, should the pharmacology and radiology department should also be contacted. So this was just a general question.

Thank You

[NightNurseRN13]

Yikes! What a mess.

Def. the supervisor needs to be informed. I wouldn't talk to the patient's until instructed to do so, but both patients need to be protected and make sure no other tests, drugs, procedures etc. are done until it's straightened out.

[Esme12, ASN, BSN, RN]

Think chain of command. Tell the charge nurse, supervisor, MD/s involved, manager/s, administration, IT, ALL departments involved, risk management, and yes an incident report should be filed. The patient does not need to be informed unless they received interventions based on those erroneous reports...and then only by instruction of the MD/administration. Entries are deleted stating wrong chart.

[VenessaNesbitt]

Thank you

[nurseprnRN, BSN, RN]

Is this reality or a seneario question OP? Cause if it is real you need to tell your instructor like yesterday, you are working on his/her license.

1) You are not working on your instructor's license. This hoary old chestnut has been passed around since time immemorial, but it is not true. Students work under the auspices of their school, and their scope of practice is defined by the relationship between the facility and the program. Students are adults and responsible for knowing their student scopes of practice and adhering to them.

2) This exact same question was asked here by another student (or maybe even this one) recently, and received the exact same answers. Homework question. What do you think, OP, and why? What do you see in your text about correcting errors in documentation?