Accurate patient records serve as a legal document that can protect nurses in the event of a dispute or investigation. Inaccurate or incomplete records can lead to serious legal consequences, including the risk of losing your nursing license.
What are common mistakes that nurses make on patient records?
Common mistakes can include transcription errors, where a nurse incorrectly records information, such as a medication dosage or a patient’s allergy, and omissions where a nurse fails to document critical information, like a patient’s medical history or current medications. Misidentification can also occur where patient records are mixed up, leading to potential treatment errors.
Illegible handwriting in handwritten records is also an issue as it can result in misinterpretation of the information.
How can I mitigate the risk of an error?
It can be helpful to promptly update records. Document patient information during the discussion with the patient, if possible, to help better ensure accuracy. It is also helpful to use clear and concise language to avoid misunderstandings or misinterpretations. Finally, double-check entries for accuracy and completeness before completing records.
What are the repercussions for a mistake?
The exact consequence will vary depending on the details. In a recent example, a nurse out of Houston faced allegations she falsified information about patient rounds. Records showed the nurse checked on the patient three times during the night, but an investigation found there was an eight-hour gap where the patient was left unattended. Such allegations would trigger an official investigation by the Texas Board of Nursing and could result in serious repercussions. In this case, the nurse chose to voluntarily surrender her license to practice nursing in the state of Texas.
Accurate patient record keeping is not just a routine task; it is a critical component of nursing practice. Nurses who face allegations of failing to accurately report their rounds or other record keeping errors are wise to take the matter seriously. Such accusations can trigger an official investigation and put one’s professional license at risk.
Attorney John Rivas is responsible for this communication.