As a nurse, properly documenting the care you provide to patients is essential. Improper documentation can lead to reduced quality of care and in some situations, injurious medical errors.
According to data collected by Johns Hopkins patient safety professionals, medical errors cause over 250,000 deaths every year in the U.S. Avoid these common documentation mistakes to enhance the level of care you provide and to reduce your chances of liability.
1. Writing illegibly
Failing to write clearly can create communication problems later on. Although it may take more time, avoiding illegible writing can protect your interests as a medical professional and the health of your patients.
2. Not dating and timing entries
Unless you work with a system that enters information automatically, every entry you input should include the date and time. You should also include your name on every page where you enter new medical information and complete entries as soon as possible after providing care to a patient.
3. Leaving blank spaces
Blank spaces can suggest a lack of care provided or unrecorded care, leaving your medical records up to scrutiny. As you fill out documentation forms, draw a line through any blank spaces where you do not need to add any information.
4. Using the wrong abbreviations
Avoid using any abbreviations someone else could misinterpret. For instance, others reading your records could confuse the abbreviation “D/C” for discharge with discontinuing prescriptions. Unless the abbreviation is a common medical one, avoid using abbreviations that could result in interpretation problems.