"Omissions" in charting..should I be worried?

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Specializes in Oncology, Med-Surgical.

I just got a call from my nursing director at a hospital where I work, usually registry. She asked if I could come in on Thursday to speak with them because they were auditing charts and found some "ommissions" in mine. Should I be worried? Thanks!

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It could be just a warning, it could be worse. Are you in a union? If yes make sure your rep is there.

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They might be trying to clean up some areas in charts that are deemed open to criticism, i.e. "covering posteriors" by insuring the charting is as complete as it can be. Trying to forgo negative outcomes in the future, even possible liability issues. This might not be confined to your charting, so don't take it personal yet. I've been asked to go over charting before and even several nurses had to redo areas because something was screwed up so badly or omitted at the time. This usually happens when a major situation is occurring. Sometimes people don't do their best charting in the heat of battle. Make certain that if you are asked to redo charting, that you agree with what you are asked to do. Use your own good judgment.

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Specializes in L&D, QI, Public Health.

I'm curious. What's your hospital's charting style? Is it chart by exception?

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