Providing the high standard of care expected in the nursing industry requires complete and accurate patient information. Unfortunately, charting mistakes can result in patient harm.
Nurses who make serious charting errors may even put their professional license at risk. Learning what some of the most common mistakes are can help you avoid this issue.
Not recording drug or health information
Proper treatment relies on accurate and complete patient history. Failing to chart information like diseases, current medications and allergies may result in nurses being personally liable for negligence in patient care.
Failing to record prior treatments
Nurses must record the details of a patient’s treatment. This is especially important when caring for and treating several patients across multiple shifts. Developments in patients may seem small alone; however, small mistakes and omissions can result in serious and potentially fatal results.
Recording information on the wrong patient’s chart
Nurses are responsible for multiple patients during their shifts. Unfortunately, mix-ups with charting are more common than many people realize. Mistakes like this can be deadly for one or more patients and leave nurses liable for what happens.
Not transcribing orders properly
If a nurse transcribes orders on the wrong chart, the wrong medication or the wrong dose, they can be held liable for resulting injuries. Nurses may also be held liable if they carry out or transcribe an order as written if they suspect or know it is wrong. These situations result in serious legal consequences and nurses must go the extra mile to protect their patient’s health and well-being.
Protecting your nursing license
Nurses who are at risk of losing their licenses have legal options. Knowing and using these options is recommended to protect their license and continue providing healthcare services.