7 Common Nurse Charting Mistakes to Avoid
As much as you may try to avoid it, nurse charting mistakes happen. While patient charting can feel tedious, it is crucial to good patient care.
Poor patient charting is a common mistake for new nurses, as nursing school provides little hands-on experience with nurse charting. Improper charting can create legal issues for you and your employer.
However, following best practices for patient charting will leave little room for errors.
Below are seven common nurse charting mistake to avoid when taking on a new nursing assignment.
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7 Common Nurse Charting Mistakes
1. Failing to obtain and chart health and drug history: There is no such thing as over-charting. If the patient tells you something about their health, chart it. It could be a small detail that offers big results in patient safety later.
2. Charting in the wrong chart: Make sure you are on the correct patient’s chart before charting. If you switch back and forth between patients while charting, double check again. Corrections in electronic medical records can be difficult to make.
3. Not documenting when medications were given: This happens when nurses get busy. You may intend to chart it later, but you never know how the rest of the shift may go. Chart medication administration in real time. Waiting until the end of the shift is poor practice.
4. Pre-charting: It may be tempting to chart a task before you perform it. Don’t do it. A lot can happen in a small amount of time that could change what you need to chart. Only chart after you have performed the task.
5. Accepting unclear orders: Never accept orders you have questions about. If you disagree with or don’t understand an order, seek clarification. Always ask for clarification if you are uncertain.
6. Improper Abbreviations: Have you ever read a chart only to scratch your head and wonder what the nurse meant? Many nurses feel that abbreviations save time. However, improper abbreviations can impact patient safety.
Check your hospital’s policy on abbreviations. Find the list of approved and unapproved abbreviations and stick to this list. If you are uncertain if an abbreviation is approved, write out the words.
7. Illegible handwriting: Most facilities use electronic medical records. However, handwritten charting will never fully disappear. Make sure that all written documentation is legible. If your charting is ever subpoenaed into court, you do not want anyone guessing what you charted.
Understanding common nurse charting mistakes is the first step to improve your patient charting. To improve even more, seek out other nurse charting tips and speak with your mentor or other nursing staff.