Accurate recordkeeping and careful documentation are an integral part of efficient nursing practice. However, mistakes may happen while attending several cases a day and documenting the details of each patient quickly. Even though electronic health records (EHR) offer an opportunity to document such details easily with pre-filled templates and fields, there is a great chance to make errors. The better way to avoid errors in documentation is to adopt a combined approach that involves both EHR and transcription. An efficient quality assessment team is also essential in addition to this.
Crucial Nurse Charting Mistakes
Here are some top mistakes that must necessarily be avoided in nurse charting as per the Nurses Service Organization (NSO).
- Not Recording Important Health Information â€“ You should record every patientâ€™s food and drug allergies, diseases, and chronic health problems on the admission sheet and in the nursesâ€™ notes so that the physicians receive the right information about the patientâ€™s condition and provide proper treatment or advice. If you neglect to record the patientâ€™s allergy to a particular medicine, the physician will assume that the patient is not allergic to that medicine while administering it and that may lead to severe complications.
- Not Recording All Nursing Action â€“ It is required to document everything you do for a patient on the chart. For example, if a nurse finds drainage with the surgical wound and could not document the dressing changed, the care provider will think the dressing has not been changed and change it again unnecessarily. Use the hospitalâ€™s standard flow sheet and ensure that all nursing actions are documented.
- Not Specifying Given Medications â€“ Every medication given should be documented by the time it is given along with the dose, and route. Suppose a nurse gives heparin to a patient as per the order just before she went off duty and does not record that on the patientâ€™s chart. When another nurse comes, she will find the order, but not see the indication of medication given as there is no record. As a result, the patient will be given another dose of heparin, which may lead to serious complications.
- Documenting on Wrong Chart â€“ This error happens often when there are two patients with the same name, same room, same condition or same doctor. If the doctor ordered administration of a medicine in a particular dose for one patient and the nurse mistakenly documents that order on the chart of the other patient with the same name, room, condition or doctor, it will surely cause complications to the latter patient as the wrong medicine may be administered incorrectly. It is better to assign a different nurse to each patient to avoid complications in such cases. The practice of flagging the patientâ€™s names on charts as well as medication records is also effective.
- Â Not Recording Discontinued Medication â€“ If a patient is supposed to discontinue a medication owing to its adverse effects, that order must be documented promptly. Suppose a doctor suspects that his patient developed an ulcer due to the high doses of medication taken for arthritis and orders to discontinue that medication. If the nurse fails to record that order on the medication sheet, other caregivers will assume that this medication is still used and administer it as before, which will deteriorate the patientâ€™s condition. It is important therefore to cross-check the doctorâ€™s orders and the medication sheet before administering the medication.
- Not Recording Patientâ€™s Reaction to Treatment â€“ In addition to monitoring the patientâ€™s response to treatment or medication, it is very important to document an adverse reaction or a worsening of the patientâ€™s condition. Otherwise, the physician may fail intervene at the right time and provide appropriate care to the patient. Report the new symptoms shown by the patients as they could develop into adverse reaction.
- Documenting Orders Incorrectly â€“ Not only should you promptly record the orders to discontinue medication, but also each and every order of the doctor. If the nurses make errors while transcribing the doctorâ€™s orders, the end result may be the same as in the case of neglecting the order to discontinue medication.
- Incomplete Records â€“ Leaving blank spaces, lines or boxes on charts is not a good practice. It can confuse the physician or other nurses about a patientâ€™s condition. Instead of leaving the records incomplete, draw a line on the blank space or write â€˜Not Applicable or N/Aâ€™. Use abbreviations in the hospitalsâ€™ approved list to avoid unnecessary misunderstandings.
Limitations of Electronic Nursing Documentation
Electronic health records are considered to be more accurate and faster systems that free up nurses to spend more time with patients. However, actually nurses complain about several disadvantages of this system such as:
- Some nurses believe that EHRs require extra time for documentation with endless logging in and out, duplicate entries, difficulty to find where to chart something, paging through unnecessary screens and increased mandatory documentation. Some of them say the system is slow and cumbersome and prompt them to chart not only what they did, but also what they didn’t do. In order to adjust the time for providing care to patients, many institutions ended up recruiting more nursing staffs.
- Many healthcare providers adopt the practice of â€˜copy-and-pasteâ€™ to save the time they lose unnecessarily for EHR documentation. But if someone copies and pastes data without verifying every word or data point, it is easy to perpetuate errors in patient charts.
- Though it is possible to save time by computerized physician order entry system (CPOE) without having to write verbal orders or interpret illegible orders, some nurses complain that this provision has reduced face-to-face communication with physicians so that there is less understanding of the plan of care for patients. Moreover, it prompts them to spend more time to check (double-check, sometime even triple-check) the orders to ensure nothing is missed.
Benefits of Combining EHR and Transcription
EHRs ensure easy access to information thereby improving the ability to make good patient care decisions, timeliness with which patient-related data is available and legibility and clarity of patient care orders. Though EHRs have the potential to improve clinician workflow, efficiency and patient safety, it is not possible to tackle nurse charting mistakes with EHR alone owing to the above mentioned limitations. This is where an approach combining EHR and transcription seems practical. In EHR transcription, physiciansâ€™ dictations can be transcribed with the help of experienced professional transcriptionists and the transcribed data populated into EHR fields. Here are the major advantages of this option.
- Structured templates limit narrative description. Even though it is possible to set up individual templates, the fine nuances of each case may have to be captured. Due to this, a complete template-based documentation may create readability challenges for the clinician who treats the patient. In such a scenario, EHR transcription is quite useful as it supports narrative description.
- With the help of a quality assessment team comprised of proofreaders and editors, you can check the files transcribed by the transcriptionists thoroughly and ensure that the data sent to EHR is accurate. This will help you to copy and paste data without risk. If you are seeking help from a professional transcription company, make sure that they provide three-level quality assessment.
- The blended approach allows using different modalities according to physician preference, practice patterns and document types. Populated structured history and physical templates may be apt in one care setting. At the same time, dictated and transcribed narrative report is the best choice for findings, assessments, encounter notes and inpatient discharge summaries. Both needs can be fulfilled with an EHR transcription system.