Inaccurate Recordings

In the Legal and Ethical class I’m attending for the BSN program, the discussion forum regarding The Florida State Board of Nursing’s (SBON) rules and regulations touches on unprofessional conduct, and inaccurate documentation is an issue listed.

Here are my thoughts on the issue.

I have witnessed occasional inaccurate recordings in a patient’s record, especially in the ED. The patient with an amputated left leg, will not have a 2+ pedal pulse in that leg, and a pupil that is recorded as round, reactive and 3mm, is not possible for the patient who’s pupil is fixed and irregular after eye surgery.

The most common inaccurate recording I notice in the ED, is when the patient’s skin is recorded as intact, and the patient presents with a huge ulcer on the buttocks. The ED is a very busy place, and sometimes  the patient to nurse ratio is out of balance, so I understand how this common mistake occurs.

Recently I was caring for two critical patients, one on 4 titratable IV drips, and another on 1 titratable drip. I cared for these patients in addition to the Baker Act patient in the hall bed, and an alcohol withdraw patient in my other room. Another patient was placed in my last room, and I stated that I was not going to assume care of that patient because it was dangerous, and the two critical patient’s really need one to one care, as they would receive in a critical care unit.

The reason I mention this story is because many mistakes, especially related to omissions or inaccurate recording, occur in the ED. The fast paced environment of the ED, the fact that everything is timed in order to prevent “fall out”, and the acuity of the patients and nurse to patient ratio, sometimes make accurate documentation or charting at the bedside nearly impossible. This is not an excuse, but it is a problem. However, if I have not had the chance to look at the patient’s skin, I leave the skin assessment empty. I would rather confess to not assessing the skin, than document inaccuracy.

According to Susan J. Westrick, accurate documentation of care is the best way to prevent negligence or malpractice claims, and incomplete, inaccurate, or conflicting documentation may give the impression of poor patient care in legal proceedings (Westrick, 2014).

The nurse must be vigilant in accurate documentation, slow down and think, and speak up if the work load is too much, or if help is needed.

Reference

Westrick, Susan J. (2014). Essentials of nursing law and ethics. (Kindle

Locations 9053-9054). Retrieved from Amazon.com.

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