8 charting errors to avoid
Nurse Leader Insider, January 28, 2020
Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Insider!
What pitfalls can you avoid to ensure proper documentation? These are eight common mistakes made:
- Failing to record pertinent health or drug information
- Failing to record nursing actions
- Failing to record that medications have been given
- Recording on the wrong chart
- Failing to document a discontinued medication
- Failing to record drug reactions or changes in patient's condition
- Transcribing orders improperly or transcribing improper orders
- Writing illegibly or incomplete records
Editor's note: The above excerpt is adapted from HCPro's online course, Nursing CE Series: Nursing Documentation - Reduce Your Risk of Liability. Check out our latest nursing resources here.
Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Insider!
Related Products
-
Strategies for Nurse Managers
Strategies for Nurse Managers is a 12-page monthly how-to newsletter that was created exclusively to help you save time...
-
Nurse Leader Insider
Our informative free e-mail newsletter for nursing professionals delivers helpful tips and advice each week!
-
Nursing Orientation Program Builder:
This binder and CD-ROM walk you through each step of a well-run orientation program so you can incorporate field-tested...
-
HealthLeaders Media Nursing Leaders
HealthLeaders Media Nursing Leaders offers concise updates on nursing leadership headlines of the week from top news...
-
Quality Improvement for Nurse Managers:
This book and CD-ROM clearly outline a nurse leader's role in quality improvement and offer simple instructions to improve...
Most Popular
- Articles
-
- Don't forget the three checks in medication administration
- Practice the six rights of medication administration
- Complications from immobility by body system
- Prevent dehydration with nursing interventions
- The consequences of an incomplete medical record
- Note similarities and differences between HCPCS, CPT® codes
- Know guidelines and subtle differences in code descriptions for laceration repairs
- Q&A: Primary, principal, and secondary diagnoses
- Skills of effective case managers
- Neurological checks for head injuries
- E-mailed
-
- Performing a SWOT analysis
- Unsuccessful v. aborted/discontinued procedures
- Q/A: Infusions in an interosseous line
- Nine ways to meet USP 797, get ready for your next survey
- Hospital Billing from A to Z: 3- and 1-day rules
- Don't bill 59025, 76818 separately without separate physician orders
- Documentation challenges for skin and dermatology coding
- Searched
