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Charting Errors

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Char_syringe_max50

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Posted over 5 years ago

 

What ids the most common charting error that nurses make? I've heard that failing to document care is the biggest problem. Is this accurate or are there other more common errors?

Pic081807_2_max50

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Rate This | Posted over 5 years ago

 

nope I think that you are right failing to document care is a big problem..... statewide...... next is how we can get nurses to chart their care and the importance of it and what it means if they do or don't chart.

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Rate This | Posted over 5 years ago

 

I have found that not dating and timing or the wrong date and time is a very common error.

Blink2_max50

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Rate This | Posted over 5 years ago

 

I was taught, "If it's not charted, it's not done!" I totally believe that! I can't stand it when a nurse says I did this and I did that, but nothing is charted, it drives me crazy!

Nana_and_grandkids_minus_noah_max50

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Rate This | Posted over 5 years ago

 

I was taught "if it's not charted, it wasn't done"' as well. Too many nurses forget to chart or don't think it's necessary to chart everything. But, that can cause problems. I worked part-time, and was often given report by another part-time nurse. Details were lacking and nothing was mentioned in the chart.It could be very confusing, if no one could fill me in on what had been going on with the patient. This happened quite often. Family members would ask me questions and I would n't have a clue. Sometimes, patients weren't charted on for days at a time. It's always best to chart . That way you're covered, no matter what.

Rebel_alliance__star_wars__-_wikipedia__the_free_encyclopedia_max50

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Rate This | Posted over 5 years ago

 

I've been told for years that I'm anal when it comes to many things in my care of pts. Documentation is probably one of the areas that gave me that label. One of the classes I teach to our new grads and externs is on charting in the ER. One of the things I try to drive home is to not chart assumptions. Chariting things like "pt sleeping", "pt resting comfortably"...etc. Colleagues in the past have charted that their pt's were sleeping when they were actually apneic from over-sedation. I could go on...but I won't.

Photo_user_blank_big

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Rate This | Posted over 5 years ago

 

Charting is quite a problem with me because sometimes the people around you will beg for your time and then i lose my train of thought. i use paper and put everything down what i did, observe, comments or anything from then on. we are discouraged to do alot of overtime but charting atleast 6 medicares, 2 monthly summaries,2 MDS, incidents, behavior monitorings,abt's, lab works, etc. needs more than 2 hours of charting. you don't chart, you didn't do it so i tried my best to write things more specifically and concise.

Ming_max50

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Rate This | Posted over 5 years ago

 

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