Record everything you do for a patient on his/her chart as soon as possible. For example, if the information regarding a dressing change is omitted, one might not realize that the patient’s wound is draining more than it should.(3) 3. Failing to record that medications have been given. Record every medication when you give it, when it’s given and include the dose, route and time. An example would be administering a second dose of heparin when there was no documentation that the ordered dose was already given.(3) 4. Recording on the wrong chart. Check your facilities policy on the system for flagging patients’ charts and medication records with similar names or other similar information that could cause confusion. Also be careful in regard to patients in the same room, have the same doctor or the same condition.(3) 5. Failing to document a discontinued medication.
If the patient is supposed to be taken off a medication, you need to document that order promptly. For example, if a medication is discontinued do to an adverse effect such as a patient with an active bleeding ulcer who should not receive anymore aspirin, the continuation of administering aspirin could lead to the deterioration of his/her condition.(3) 6. Failing to record drug reactions or changes in the patient’s condition. You need to document your observation of the patient’s health status/condition and your actions taken as well as documenting the patient’s comments about his/her condition and the actions taken.(3) 7. Transcribing orders improperly or transcribing improper orders. Anytime you are unsure about a drug order, check it with the prescribing doctor, your nurse manager or follow the policy of your facility.(3) 8. Writing illegible or incomplete records. Imagine your embarrassment at being called to testify and not being able to read your own handwriting or having to admit that the information recorded is incomplete. To play it safe, remember each of these good charting practices: Print if your handwriting is difficult to read. Sign your full name and title somewhere on every page where you’ve charted. Don’t leave blank spaces, lines, or boxes on charts. If you don’t use the space, draw a line through it or write N/A (not applicable). Don’t use abbreviations that aren’t on your facility’s approved list of abbreviations. Chances are someone could misunderstand your abbreviation. And years later, you may not even remember what it meant. Record every nursing action as soon as possible after you’ve finished it. Document enough to convince a reader that the patient was adequately cared for.(3) Incident Reports/Unusual Occurrence Reports Even though the main focus of this program is not in regard to incident / unusual occurrence reports, we do need to discuss the importance of the report and when to file one. An incident/unusual occurrence report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a
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- Summer '15
- Health care provider, medical error, Iatrogenesis