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Don’t take chances with incomplete documentation: Eight charting errors to avoid

Staff Development Weekly: Insight on Evidence-Based Practice in Education, March 26, 2004

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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 illegibly or incomplete records

Editor's note: The above excerpt is from the new online course "Nursing CE Series: Nursing documentation-reduce your risk of liability." For more information on this and other Nursing courses, go to www.hcprofessor.com. and click on Nursing CE Series. HCPro, Inc. is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation (ANCC).

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