Charting might not be the most glamorous aspect of your job, but it’s essential. The whole care team relies on patients’ medical charts to make sure they’re giving the right care at the right time. If charts are incomplete or inaccurate, it could hurt the patient and potentially result in a lawsuit.
Everyone makes mistakes. But some charting errors are more common than others, and almost all are preventable if you know what to look out for. We’ve found five examples of real-life charting mistakes to help give you an idea of how errors happen and — perhaps more importantly — how to avoid them. In each, we lay out what happened and how, as well as the key takeaways you can use to avoid making similar mistakes.
Case Study #1: Missing Documentation
The Charting Mistake
A doctor ordered frequent leg exams for a patient, who was receiving uterine artery embolization, but the patient’s records showed no evidence of the exams ever being performed.
How It Happened
It’s unclear whether the nurses actually performed the exams, but if they did, they didn’t document them.
The Result
Though the clinician ordered frequent leg exams, the patient claimed they never happened. A massive blood clot was removed from the patient’s external iliac artery, resulting in nerve damage. The patient sued and won a $1.5 million verdict, in part because the nurses didn’t have the documentation to prove they did the exams as ordered.
Your Takeaway
Document every procedure you do, as well as its results. If you aren’t able to complete an order, record that, too. As the medical adage goes, “If you didn’t write it down, it didn’t happen.”
Case Study #2: Copying & Pasting Inaccurate Information
The Charting Mistake
Physicians copied and pasted an incorrect diagnosis in a patient’s chart, which was then used to treat the patient.
How It Happened
A resident misdiagnosed the patient with adrenal insufficiency and wrote it in the patient’s chart. The consulting and attending physicians used a feature of the electronic health record (EHR) that allowed them to copy and paste resident’s notes as their own and reiterated the incorrect diagnosis in their own notes.
The Result
Clinicians relied on the inaccurate assessment when caring for the patient, and the patient was treated with steroids for adrenal insufficiency, despite not actually having it. The patient then died as a result of the medication error.
Your Takeaway
Avoid copying and pasting old information into new chart entries unless you’ve personally verified that the information is correct.
Case Study #3: Documenting in the Wrong Chart
The Charting Mistake
The wrong chart was used to document a patient’s care in the emergency department.
How It Happened
When the ambulance arrived with the patient, the driver told the emergency department clerk the patient’s name. The clerk pulled up a medical record in the EHR with the same name but didn’t realize the birthdate was wrong.
The Result
By the time the ambulance driver raised questions about the patient’s age on the record, the medical team had already started drawing labs and running tests based on the wrong patient information. Thankfully, no known harm came to the patient, but the medical team may have dodged a bullet. Had they given medications, an unknown drug allergy could have occurred.
Your Takeaway
Double-check that you have the right patient record by verifying both the patient’s name and birthdate. If you aren’t sure that you have the right patient, stop the care (if possible) and confirm the patient’s identity right away.
Case Study #4: Not Documenting as Soon as Possible
The Charting Mistake
A clinician didn’t enter a note into the patient’s chart until several days after the visit. The delay meant that another clinician, who was treating the patient in the meantime, prescribed them a potentially dangerous medication.
How It Happened
After seeing a patient just before lunchtime, the clinician got sidetracked and didn’t record his notes in the patient’s chart. Four days later, the clinician returned to work after a long weekend and noticed his mistake. He added his notes but backdated them so they would be associated with the day the patient was seen.
The Result
During the patient’s initial visit, the patient described experiencing symptoms that were possible reactions to a prescribed medication. Because the first clinician didn’t enter his notes the day the patient was seen, the second clinician to care for the patient over the long weekend didn’t know about the possible reaction and prescribed the very same medication.
Your Takeaway
Input the patient data as soon as you can. If life happens and there’s a delay between seeing the patient and inputting your documentation, follow your organization’s guidelines on changing the reference date in the EHR. Even if the time you enter the note is hard-coded into the system, associating the note with a previous date of service may confuse (or even mislead) other clinicians who rely on your notes to decide and administer care. Starting the note with a quick “Late Entry,” followed by the date and time of the patient contact, can help avoid any confusion.
Case Study #5: Inputting Data Incorrectly
The Charting Mistake
Providers made a mistake when noting the dose of a medication during a patient transfer to a new facility; this error resulted in the patient receiving a dosage that was 10 times the appropriate amount.
How It Happened
After being treated for congestive heart failure, a patient was transferred to a rehab facility. There, clinicians noted in the transfer medication list that the patient was receiving 0.625 mg of digoxin daily, but it was a typo: She was actually supposed to get 0.0625 mg. Even though her home medication list had the correct number, it didn’t list the unit of measurement for the dose, and the mistake wasn’t caught during medication reconciliation. When the admitting resident entered the patient’s information into the rehab facility’s EHR, the system wouldn’t allow milligrams, so they converted the incorrect dose to micrograms. Later, the pharmacist overrode an alert warning the dose was too high and didn’t verify the correct number with the ordering clinician.
The Result
The RN on duty added 625 mcg daily to the patient’s medication record — the patient should have received just 62 mcg — and noted that the meds were given. After four days of receiving 10 times the appropriate dose, the patient complained of nausea and her heart rate plummeted into the 30s. Her blood work came back with high levels of potassium and digoxin. The patient was transferred to a different facility and returned to baseline, but she died six weeks later from renal failure and cardiomyopathy.
The admitting nurse at the rehab facility later went back and altered the patient’s medical records to make it look like the medication had never been given at the facility. The patient’s family sued and settled for over $1 million.
Your Takeaway
Before giving a medication, verify the dose with the ordering clinician — especially if it looks wrong — and don’t bypass warnings in the EHR or ordering system unless you’re absolutely sure the dose is correct. If you do make a mistake, don’t go back and change medical records to cover it up.
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