Protect Your License from this Common Nursing Documentation Blunder

You would probably agree that the medical industry can ask a lot of its nurses. With the introduction of electronic medical records, you may also agree that the responsibilities that nurses carry are becoming even more demanding. In addition to their usual responsibilities and patients, nurses must now learn the new software used for electronic charting. What happens when the demands on the nurse become too overwhelming? The answer is not pretty. Shortcuts are taken, duties are neglected, and worst of all, mistakes are made. The result is a lowered quality of care and a failure to meet some Standards of Care. However, there is one common shortcut that nurses take that can cost them their nursing license.

In recent trends, one of the first things to suffer when a nurse is overwhelmed is the integrity of the medical documentation. "Late charting" is a technique used by many nurses and is allowed or even promoted by facilities. It has become common practice for nurses to wait until the end of a shift or even stay late to complete all of their charting. In these situations, the liability to the facility and the nurse increases substantially.

There are many unfavorable situations that can arise from late charting. To name a few: nurses may be too busy to remember exactly what was done with a patient, nurses may confuse patients and put information on the wrong chart, or miscommunication between staff members and shifts can arise. In an example taken from an actual lawsuit, a day nurse administered heparin to a patient by intravenous push. An hour later, when the next shift took over, they saw the order for heparin with no documentation that it had been given. So she gave the patient the same dose. The patient began to hemorrhage and went into hypovolemic shock. He recovered and subsequently successfully sued the hospital. While this particular nurse was lucky enough to get out without harm to her license, many nurses have had their licenses placed on probation for medication errors very similar to this one.

The darker side of late charting is that it allows nurses to cover up any laziness or negligence. However, little do most nurses know that these undesirable practices can be tracked. This is where nurses really get themselves in trouble. The new electronic medical record software keeps track of each user and exactly when they make entries. So, while the nurse may enter a specific date and time for an event, the system logs the exact date and time the entry was entered. This hidden information is called Metadata. Metadata has proven to be the smoking gun in many medical malpractice and negligence lawsuits. In another example of an actual lawsuit, a patient passed away in a hospital. When the hospital was sued, the Metadata was exposed in the trial and it did not match up to the events entered by the nurse. The nurse recorded that a required medication was given on time, but the Metadata showed that the entry of the event actually happened after the patient passed away. How could a nurse administer medication to a dead patient?

What can you do to protect yourself and how late is too late for charting? The best way to avoid any problems with late charting is to chart in real-time. This is the most reliable and accurate way to chart. This was a standard with paper records. With electronic records, it may take a little longer as the nurse familiarizes themselves with the new system, but that time will decrease with practice. There may come a time when you find yourself in a situation where real-time charting is impossible. In this scenario, the medical industry and most facilities consider a maximum of one hour after an event to be acceptable for accurate charting.

If you are tired of dodging landmines like this in your nursing job, there are other options for your nursing career. Why be forced into a situation where you find yourself and your livelihood at risk? One small mistake, misunderstanding, or any inaccurate charting can cost you your license. Don't accept a tough situation as your reality. Make the decision to put yourself in a better position. As an Advanced Legal Nurse Consultant (ALNC) you can use your medical expertise to work in the legal field. You can avoid dangerous situations and potential injury while earning much more money and receiving much more respect as an ALNC.