Are You an Illinois Nurse Accused of Committing a Medical Error?

 Posted on March 18, 2022 in Medical License Defense

According to data collected by John Hopkins patient safety professionals, medical errors are responsible for more than a quarter of a million deaths each year in this country. This major study used data collected over an eight-year period and put a spotlight on the dangers medical errors pose to patients. One of the most important factors in preventing these errors is the proper documentation by the nursing staff of the care provided to patients. Accusations of improper documentation by nurses can lead to disciplinary action or even suspension of your nursing license. The following are some of the more common documentation errors nurses are accused of making.

Illegible Writing

Although the majority of patient records are done electronically, there are still occasions where a nurse will need to handwrite patient information on a document or file. It is important that writing be done clearly and be legible for anyone who needs to read it.

Failure to Date/Time Entries

Some systems automatically enter the date and time of an entry, but if the system you are using does not offer that option, or you are handwriting the information, every entry should have the date, time, and your name.

Leaving a Blank Space

If a space is left blank, that can indicate lack of unrecorded care or even lack of provided care. This can raise questions on the quality of care you are providing. If you do not have information for a space, draw a line through it.

Using Incorrect Abbreviations

Make sure any abbreviations you are using are correct and could not be misinterpreted as something else. In fact, it is best to avoid the use of abbreviations unless it is a commonly used by medical professionals.

Failure to Document Any Omitted Treatments or Medications

Regardless of the reason, any time a treatment or medication is omitted, it is crucial to document that information.

Failure to Add Information Right Away

Failure to record any information immediately or right after an event can result in forgetting to record it at all or forgetting to add details that are important and should have been recorded. If you do make a late entry, make sure to include the date, time, the actual time the event occurred, and mark the entry as late.

Failure to Document Any New Symptoms or Condition the Patient Is Having

Always document any new symptom the patient has or any new patient they develop. You should also include the time you noticed these symptoms, the action taken, and the patient’s reaction.

Making the Entry on the Wrong Chart

Electronic records are supposed to make keeping medical records an easier and more streamlined process. However, there are drawbacks if one is not careful. One of those drawbacks is that there is a higher risk of entering information on the wrong patient’s chart.

Call an Illinois Professional License Defense Attorney

If you have been accused of unprofessional behavior or committing a medical error, contact an Illinois nursing license defense attorney from The Law Offices of Joseph J. Bogdan, Inc. to find out how we can help you defend against these accusations. Call 630-310-1267 to schedule a free consultation.

Sources:

https://www.medcominc.com/medical-errors/prevent-documentation-errors-nursing/

https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us