Here’s advice that can help keep your charting at its best–and keep you out of legal trouble.

by M. DeMilliano, BSN, JD

1. Failing to record pertinent health or drug information

Suppose the patient has an allergy or a disease (such as diabetes, hemophilia, or glaucoma) that his caregivers need to know about. But you forget to record that on his chart. You could end up in court, as did a nurse at a large metropolitan hospital.

The nurse neglected to record her patient’s penicillin allergy in the admission notes. Because the intern didn’t know the patient was penicillin-allergic, he gave the patient a penicillin injection. The patient, who was incoherent and couldn’t tell the intern about the allergy, went into anaphylactic shock and suffered irreversible brain damage. At the trial, the court found the nurse guilty of negligence.

So you make sure you ask about every patient’s food and drug allergies, diseases, and chronic health problems. And record the information on the admission sheet and in the nurses’ notes. Alert other staff members to drug allergies by putting a bright label on the outside of the patient’s chart, according to hospital policy.


2. Failing to record nursing actions

Record everything you do for a patient on his chart as soon as possible.

Let’s say the day nurse observes heavy drainage from a surgical wound and changes the patient’s dressing. But she forgets to record the dressing change and her assessment of heavy drainage before she leaves.

The evening nurse also notices heavy drainage from the wound. She checks the nurses’ notes and finds no evidence that the dressing was changed. She considers the amount of drainage normal for a period of several hours. She changes the dressing but, like the day nurse, forgets to chart her action.

The night nurse does the same. Is the condition getting more serious? Is the patient’s life in jeopardy? No one knows because no one realizes that the patient’s wound is seeping more than it should.

The usual excuse for not charting is “not enough time.” Consider flow sheets that you can insert in the patient’s chart at the end of the shift. If your hospital has standard flow sheets, use them. If it doesn’t, ask for them.


3. Failing to record that medications have been given

Record every medication you give when it’s given–including the dose, route, and time.

A day nurse gave a patient heparin by intravenous push just before she went off duty. An hour later, the evening nurse saw the order for heparin–but no indication that it had been given. So she gave the patient the same dose. The patient began to hemorrhage and went into hypovolemic shock. He recovered–then successfully sued the hospital.

Both nurses made mistakes here. The first should have recorded that she’s given the dose. The second should have been suspicious when she saw the order for heparin but no evidence that it had been given. She could have:

  • asked the patient if he’d received the medication.
  • called the pharmacy to see if the dose had already been furnished.
  • called the first nurse at home.

So always investigate when you suspect a medication may have been given but not recorded.

4. Recording on the wrong chart

You can’t be too careful in any situation that might lead to confusion between two patients: same last name, same room, same condition, or same doctor.

Mrs. B. Moyer and Mrs. C. Moyer were on the same unit. Mrs. B. Moyer was being treated for severe hypertension; Mrs. C. Moyer, for acute thrombophlebitis. Mrs. C. Moyer’s doctor ordered 4,000 units of heparin for her.

The nurse mistakenly transcribed the heparin order onto Mrs. B. Moyer’s chart and administered the heparin. Mrs. B. Moyer started bleeding.

When you have two or more patients with the same name, be sure a different nurse is assigned to each patient; develop a system of flagging the patients’ names on charts and medication records. And check wristbands before you give medications.

5. Failing to document a discontinued medication

If the patient is supposed to be taken off a medication because of its adverse effects, you need to document that order promptly.

A doctor suspected that his patient, who was taking high doses of aspirin for arthritis, had developed an ulcer. So he discontinued the medication. But the patient’s nurse forgot to record the order on the medication sheet, and she and the other nurses continued giving aspirin. The ulcer bled, and the patient eventually underwent a partial gastrectomy because her condition deteriorated. She sued the hospital for the nurses’ negligence and won.

Cross-checking the doctor’s orders and the medication sheet before giving the medication would have prevented this patient’s serious complication.


6. Failing to record drug reactions or changes in the patient’s condition

Monitoring a patient’s response to treatment isn’t enough. You need to recognize an adverse reaction or a worsening of the patient’s condition, then intervene before the patient is seriously harmed.

A patient complained of nausea, dizziness, abdominal pain, and itchy skin shortly after receiving his first 100-mg dose of nitrofurantoin macrocrystals (Macrodantin). His nurse wasn’t concerned, though. By evening, after two more doses of the medication, he was vomiting and had a high fever, urticaria, and early symptoms of shock. He sued his nurse for negligence.

The fact that most patients don’t have adverse reactions to certain drugs shouldn’t lull you into carelessness; most drugs can cause problems in some patients who take them. So observe your patients closely, consider the possibility of adverse reactions when a patient reports new symptoms, and follow up appropriately.


7. Transcribing orders improperly or transcribing improper orders

If you transcribe orders on the wrong chart or transcribe the wrong dose, you can be held liable for any resulting injury. You can also be held liable if you transcribe or carry out an order as it’s written if you know or suspect the order is wrong. And you should be familiar enough with the medications, procedures, and activities you’re responsible for to know when something isn’t right.

A doctor ordered 5 ml of atropine for a patient on the coronary care unit. He meant to order 0.5 ml, but he didn’t include the zero or write the decimal point clearly. The nurse transcribed the order as 5 ml, although she didn’t think it seemed right. She decided the doctor knew best and didn’t check the dose before recording it.

Anytime you’re unsure about a drug order, check it with the prescribing doctor. And if you’re sure the order is wrong, tell the doctor why you can’t administer the drug, then notify your nurse-manager. She’ll probably talk with the doctor and tell him that he’ll have to give the drug himself.


8. Writing illegible or incomplete records

These mistakes rarely cause lawsuits. But they can rear their ugly heads in the midst of lawsuits. 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 the hospital’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.
  • Write enough to convince a reader that the patient was adequately cared for.

Such careful attention to charting is never a waste of time. It helps you demonstrate the good care you’ve given, saving yourself the need to defend it in court someday.

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