Which action would the nurse take to rectify a documentation error?
Strike with a single line, tag it as an error, put initials, and document the correct medication. If an error occurs during documentation of the clients health information, the nurse puts a straight single line through it, tags it with the word error, and initials and dates it.
What happens if there are documentation errors in the medical field?
Failure to document a patients condition, medications administered, or anything else related to patient care can result in poor outcomes for patients, and liability issues for the facility, the physician in charge, and the nurse(s).
What are the consequences of medical errors?
While unintentional medical errors have an impact on patients and their families, they may also contribute to adverse mental and emotional effects on the involved provider(s). These may include burnout, lack of concentration, poor work performance, posttraumatic stress disorder, depression, and even suicidality.
What is the correct way to fix a handwritten entry made on a medical chart?
When an error is made in a medical record entry, proper error correction procedures must be followed. Draw line through entry (thin pen line). Initial and date the entry. State the reason for the error (i.e. in the margin or above the note if room). Document the correct information.
What is the proper way to correct a mistake in a medical record?
If you want to have a mistake fixed, follow these steps: Step 1: Contact your provider. Contact your providers office and find out what their process is for updating or correcting your health record. Step 2: Write down what you want fixed. Step 3: Make a copy of your request. Step 4: Send your request.
How do you correct errors in nursing documentation?
Make the correction in a way that preserves the original entry. Draw a single line through the erroneous entry and write the time, date, and your name. Identify the reason for the correction. Include the rationale in your notation; for example, mistaken entry, wrong medication name written.
What are the consequences of medical errors?
While unintentional medical errors have an impact on patients and their families, they may also contribute to adverse mental and emotional effects on the involved provider(s). These may include burnout, lack of concentration, poor work performance, posttraumatic stress disorder, depression, and even suicidality.
What should be done when an error is found in an electronic health record?
In general, a narrative entry in the medical record statement indicating that an error has been made, and is being corrected, is the best procedure. When a lab or diagnostic report is involved, the facility director or pathologist should assume the responsibility for insuring that such an entry is made.
How can nurses improve documentation?
Tips for Great Nursing Documentation Be Accurate. Write down information accurately in real-time. Avoid Late Entries. Prioritize Legibility. Use the Right Tools. Follow Policy on Abbreviations. Document Physician Consultations. Chart the Symptom and the Treatment. Avoid Opinions and Hearsay.
How should you handle an error in your documentation?
In Brief Dont obliterate the mistaken entry. Make the correction in a way that preserves the original entry. Identify the reason for the correction. Follow facility policy when adding late information. Never alter words or numbers after youve written them. Correct mistakes promptly.
