Question

Identify and differentiate the regulation and methods of documenting for the following: an error in charting, a late entry, and an error that occurred regarding care for a client.

Answer 1

ERROR IN CHARTING

Nurses are on the front line of defence in the medical field, being adequately trained early on proper charting/ documentation can help avoid such medical errors, save lives and help protect their employers.

Types of errors in CHARTING are :

* Sloppy or illegible handwriting

* Failure to date, time and sign a medical entry

* Lack of documentation for omitted Medications and treatments

* Incomplete or missing documentation

* Adding entries later on

* Documenting subjective data

* Not questioning incomprehensible orders

* Using the wrong abbreviations

* Entering information into the wrong chart.

The appropriate method to correct an error is ,

- Make a new entry with today's date and time

- stating that you are correcting an error in a previous entry

- Give the date and time of the previous entry

- Enter the corrected data or explanation.

LATE ENTRY

Any clinical provider documenting within the health record may need to enter a late entry. The organization should clearly define how this process occur with in their system. Typically, late entries apply to direct documentation only for example, physician orders, progress notes or nursing assesments.

Examples of institutional methods regarding late entries :-

* Identify the new entry as a " late entry"

* Enter the current date and time - do not attempt to give the appearance that the entry was made on a previous date or an earlier time.

* The entry must be signed

* Identify or refer to the date and circumstances for which the late entry or addendum is written.

* When making a late entry, document as soon as possible. There is no time for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes.

* An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry.

* Document the date and time on which the addendum was made

* Write addendum and State the reason for creating the addendum, referring back to the original entry.

* When writing an addendum, complete it as soon as possible after the original note.

ERRORS THAT OCCURRED REGARDING CARE FOR A CLIENT

Nursing errors commonly resolve around patient falls, infections, Medication errors, and equipment injuries.

The regulation and method of documenting an error that occurred regarding care of a client are,

* Monitor patients regularly and document interventions performed

* Report adverse events immediately to the nurse manager or supervisor

* Check health care providers orders for monitoring and notification intervals, such as BP parameters, fever, heart rate, and abnormal heart rhythms.

* Document as patient condition warrents . For example, if the patient is declining, document every interventions and notification you perform.

* Address all signs and symptoms of distress.

* Document the time and content of all health care provider notifications.

* Ensure all documentation is on the correct patient.

* Document patient education and patient and care giver comprehensive of the information.