By the time your shift at the hospital emergency room is over, you’re exhausted – and that could lead to serious charting errors.
As one expert said, “Change of shift is the riskiest time in the ED, as the handoff process is not perfect and information may be lost.” That lost information could lead to dangerous consequences for patients and providers alike, so it’s critically important to document everything about a patient’s care before you leave.
Verbal conveyance isn’t enough to protect patients or nurses
Sure, you can tell the incoming nurse that you just gave the patient in Room 20 a bolus of pain medication, but that means nothing if the information doesn’t make it into the patient’s chart. In general, you never want to rely on the next person to put what you’ve said down in writing – or even remember.
Aside from failing to document pain medication doses, other common charting errors include things like:
- Writing information down in the wrong patient’s chart
- Failing to note recent changes in a patient’s condition
- Forgetting to note that a specific medication has been discontinued
- Failing to note all your nursing actions, including taking the patient’s vitals
As staffing issues continue to be a problem in hospitals across the country and emergency rooms continue to be inundated with patients, it’s easy to let the pressure push you into shortcuts – but you could be putting your license permanently at risk.
If you’ve been accused of a charting deficiency and your license and reputation are already at stake, find out what legal options you have to protect your future.