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Documentation: Eight charting errors to avoid

Case Management Weekly, March 30, 2004

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Documentation: Eight charting errors to avoid

Incomplete documentation in patient clinical records can cause your organization legal and settlement fees, cause you to lose your license, contribute to inaccurate statistical databases, cause lost revenue/reimbursement, and result in poor patient care by other healthcare team members. That's why every organization should ensure accurate and complete clinical documentation.

Below are eight common mistakes to avoid. Share these pitfalls with your staff to ensure proper documentation:

1. Failing to record pertinent health or drug information
2. Failing to record nursing actions
3. Failing to record that medications have been given
4. Recording on the wrong chart
5. Failing to document a discontinued medication
6. Failing to record drug reactions or changes in patient's condition
7. Transcribing orders improperly or transcribing improper orders
8. Writing illegible or incomplete records

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