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8 charting errors to avoid


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What pitfalls can you avoid to ensure proper documentation? These are eight common mistakes made:

  1. Failing to record pertinent health or drug information
  2. Failing to record nursing actions
  3. Failing to record that medications have been given
  4. Recording on the wrong chart
  5. Failing to document a discontinued medication
  6. Failing to record drug reactions or changes in patient's condition
  7. Transcribing orders improperly or transcribing improper orders
  8. Writing illegibly or incomplete records

 

Editor's note: The above excerpt is adapted from HCPro's online course, Nursing CE Series: Nursing Documentation - Reduce Your Risk of Liability. Check out our latest nursing resources here.