The goal, of course, is to document perfectly every time. In an ideal nursing world, every patient’s chart would be an unblemished work of art. But, this is reality. As nurses, and as humans, we are prone to make mistakes. So what do we do when this happens? What are the appropriate steps to fix a charting error?
Medical records, in hard copy or computer/digital form, are legal documents providing proof of the care patients received and their responses to that care. Medical records that are poorly maintained, incomplete, inaccurate, illegible, or altered, create doubt regarding the care given to the patient and can cause suspicion in a jury–aside from the clinical consequences of having a useless record. When a charting error is made, never erase or try to hide it. Draw a line through the error, and write “mistaken entry” followed by your signature and date. Never use white-out on charts.
In need of more charting tips? Here you go . . .
- Don’t leave charting until the end of your shift when you must rely on memory and may be pressed for time.
- Don’t record staff conflicts or staffing problems.
- Don’t alter a record.
- Don’t write prejudicial or sarcastic statements. Keep it professional.
- Don’t chart someone else’s statements or descriptions unless it is crucial, in which case quote the statement and give the source.
- Don’t name a second patient. If you must, use “roommate,” bed number, or other descriptive term.
- Don’t use words associated with errors, such as “by mistake” or “somehow.” Let the facts speak for themselves.
- Don’t be vague, but don’t ramble either. Maximize time, conserve your resources, and write the facts.
- Don’t mention incident reports. These are confidential and are filed separately. Consult your institution for the specifics.
- Don’t ‘blanket chart’ or pre-chart. Recording something you did not do is fraud and may be prosecuted.
Editor’s Note: This excerpt was adapted from HCPro’s Quick E! Charting. Click on the Quick E! link at the top right of this page to learn more about all 10 titles in the clinical reference guide series.
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