Are You Charting Correctly? What To Look For In A Patient’s Chart

For nurses, charting is an essential part of the job. But are you doing it correctly? Filling out a chart the wrong way can have serious consequences for a patient’s care. There’s a saying in medicine: “If you didn’t chart it, it didn’t happen.” This underscores the serious importance of recording everything relevant about a patient’s ongoing medical care. If there’s a legal issue, like a personal injury lawsuit or a worker’s compensation claim, the patient will need proper medical documentation. In the event of a malpractice suit, you could potentially be called into court years after you actually saw the patient.

Proper charting gives you, the patient, and their physicians an accurate record of their care. Unfortunately, nurses are all too often overworked, leaving them pressed for time. When you’re in a hurry, it’s all too easy to neglect to fill out a patient’s chart correctly. But there are some things you absolutely must record — it’s a matter of patient safety.

Common Charting Mistakes

There are several types of mistakes that nurses often make with a patient’s chart. These mistakes and omissions can potentially be quite serious, even serious enough to result in a lawsuit. The first step to good charting is to avoid these common missteps.

• Failing to record pertinent health or prescription information. If the patient has an allergy or disease, or they’re on a particular prescription drug, anyone providing care for them needs to know. An unrecorded penicillin allergy, or drug that interacts with other medications, could have devastating consequences later on. You need to record any and all medically relevant information that you can. Brightly colored labelling can help alert other nurses and physicians to serious allergies.
• Failing to record the actions you took. You also need to record any actions that you have taken with the patient. This usually happens because the nurse is pressed for time. But this is one of the most important things you need to document.
• Failing to record which medications have been given. Many prescription drugs are very dangerous in the event of an overdose. If two different nurses dose the patient twice, their life could be in danger. If you’re ever unsure when looking at a patient’s chart, ask the patient if they’ve been given the medication yet. If they’re unable to respond, contact the hospital pharmacy, or call the nurse that last saw the patient.
• Writing on the wrong chart. This happens more often than you might think. When two patients share the same room, nurses can often mix up their charts. This can also happen with patients who have the same last name, or who are seeing the same doctor.
• Not recording drug reactions or changes in condition. If the patient has a reaction to a drug, or if their condition has changed in any way, you need to record it on their chart. In the event of an adverse reaction or worsening condition, you or another healthcare worker will need to intervene as soon as possible. Adverse drug reactions are relatively rare, but they do happen. If a patient reports new symptoms, listen to them.
• Improper transcription of orders. If you transcribe the wrong order on someone’s chart, you could be at fault in the event of a lawsuit. This is true even if you carry out an order that was mistaken. The simple omission of a decimal point in a dosage could have serious consequences. Trust your education and your instinct.
• Writing illegibly. Other people need to be able to read what you’ve written. You don’t need to create gorgeous, flawless calligraphy, but it does need to be legible. If you use abbreviations, make sure they’re on your hospital’s approved list.

Don’t Neglect a Chart Because You Feel Rushed

Most mistakes in patients’ charts happen because the nurse or physician was in a hurry. No matter how pressed you are for time, you still need to slow down and make sure the chart is filled out accurately. If you’re trying to multitask and you’re being pulled in a thousand different directions, you’re far more likely to make a mistake.

Slow down for just one moment to focus on the chart. For the patient to receive the right medical care, it’s crucial that their chart is accurate, objective, and up to date. Charting errors could have serious consequences, both medically and legally.