Are you a Certified Nursing Assistant (CNA) practicing in the U.S? Wondering what the common charting errors in nursing are? Are you confused about how to avoid those common charting errors in nursing? If so, you are at the right place.
This article can help you learn more about some of the most common charting errors in nursing and how to avoid them.
9 Common Charting Errors in Nursing
As a CNA, it is very essential to be aware of some of the common charting errors in nursing. A Certified Nursing Assistant (CNA) has to be very careful when performing their tasks because nursing errors can put the patient’s life at risk. CNAs are required to perform tasks with the utmost concentration and accuracy.
Here are some of the most common charting errors in nursing as follows:
- Failing to document prior treatments.
- Failing to record drug information.
- Recording on the wrong patient’s chart.
- Failing to record that medications have been administered.
- Failing to record drug reactions.
- Not documenting discontinuation of a medication.
- Recording improper orders or recording orders incorrectly.
- Improper abbreviations.
- Illegible handwriting.
Let’s now learn about some of the most common charting errors in nursing in more detail.
FAILING TO DOCUMENT PRIOR TREATMENTS
As a Certified Nursing Assistant, there are many patients under your care. It is essential to record every patient’s treatment details and document them separately. CNAs are required to record, document, and maintain a separate patient chart for easy understanding of a patient’s treatment history and access other details regarding the patient.
As far as the healthcare industry is concerned, even a small error can lead to larger consequences by putting the patient’s life at risk. Every patient goes through different treatments and it is essential for a CNA to record and document every patient’s treatment history.
FAILING TO RECORD DRUG INFORMATION
Another common charting error in nursing is CNAs failing to record drug information. In a patient’s chart, documentation of drug-related information plays a vital role in understanding a patient’s health condition. It also helps doctors diagnose patient’s health issues with a record of drug-related information. It also helps the healthcare team stay aware of any drug allergies the patient might have or develop.
RECORDING ON THE WRONG PATIENT’S CHART
As CNAs, you get to work with many patients and have many patients under your care. Recording on the wrong patient’s chart is one of the most common charting errors in nursing. It is very essential for a CNA to ensure that patient details are recorded on the right patient’s chart.
This charting error may lead to providing the wrong treatment or medication to the wrong patient. As a CNA, you must verify that you are documenting the information on the right patient’s chart before you document them.
FAILING TO RECORD THAT MEDICATIONS HAVE BEEN ADMINISTERED
At times, lifesaving drugs can become life-threatening when the drug is administered improperly. As a CNA, it is very important to record details separately regarding the medications administered for every patient under your care. Make sure to document details, such as the name of the medication, dosage of the medication, route, and time of administration for each medication.
Overdosing of medications or adverse interactions can put the patient’s life at risk. It also helps the healthcare team member understand the patient’s medical history in a much better way and may also help with better diagnosis.
FAILING TO RECORD DRUG REACTIONS
When it comes to handling patients, CNAs are required to have excellent attention to detail. It is essential for a CNA to observe drug reactions in patients under their care, as well as record and document them whenever necessary. They are also responsible to record and document previous drug reactions if the patient has had them previously.
This helps to ensure that the wrong drugs are not prescribed to patients. Certain patients may develop allergies to certain drugs and it is the CNA’s responsibility to closely observe and document the reactions every now and then because this helps doctors understand and diagnose in a much better way.
NOT DOCUMENTING THE DISCONTINUATION OF A MEDICATION
Some patients may discontinue their medications due to certain reasons. It is the CNA’s responsibility to document such details on the patient’s chart. Recording those medications can help doctors understand the reasons behind it being discontinued. It is also important to learn more about the reason why the patient discontinued that medication.
RECORDING IMPROPER ORDERS OR RECORDING ORDERS INCORRECTLY
When you as a CNA handle many patients it is very common to record improper orders or record an order incorrectly. This could put the patient at risk when they are given the wrong medications. It is essential for CNAs to record orders properly and correctly as it might put the patient in danger if they don’t. Wrong medications and wrong dosages of medications, even if they are life-saving drugs, can become life-threatening.
IMPROPER ABBREVIATIONS
As a CNA, you may have to record the details in a much faster way. At such times, abbreviations come handy as it saves a lot of time and helps you record more information on the patient’s chart. It is very common for a CNA to have written the wrong abbreviation when they were recording the patient’s details. This can also lead to the wrong diagnosis, the wrong administration of medication, or the wrong treatment.
ILLEGIBLE HANDWRITING
Another common charting error in nursing is having illegible handwriting. As a CNA, you will be required to work in a fast-paced environment when you are recording patient details in the chart.
At such times, CNAs may end up having illegible handwriting. That might be difficult to read and understand after a while. The chances are high that a CNA misunderstands what they had recorded in the patient’s chart.
Now that you are aware of some of the common charting errors in nursing, it is essential to also learn about the ways to avoid charting errors in nursing. Let’s discuss some of the ways to avoid common charting errors in nursing.
How to Avoid Charting Errors in Nursing
Some of the ways to avoid common charting errors in nursing are as follows:
- As a CNA, make sure to record and document patient details in their respective charts immediately without postponing it.
- Make sure to have clear and readable handwriting.
- Memorize the abbreviations and make sure to use the right abbreviations when you record patient details.
- Make sure you are recording the right details on the right patient’s chart.
- Always cross-verify drug details, dosages of medications, and times of administration of medications with the members of the healthcare team.
- Make sure to record and cross-verify the patient history with the patient before you hand it off to the members of the healthcare team.
Wrapping Up
If you have been looking for some of the most common charting errors in nursing and ways to avoid them, this article should have helped you gain a better understanding. As a CNA, it is important to practice performing tasks without committing any errors because you may be working with patients who fall under the senior population category. Even a small mistake in the healthcare industry can put the patient’s life at risk. CNAs are required to work with the utmost concentration and accuracy at work.
If you are interested in taking the CNA exam or know someone who is planning to become a CNA, refer to our free CNA practice test to help you efficiently prepare for the exam.
Frequently Asked Questions (FAQs)
What are the top 5 most common medical errors?
The top 5 most common medical errors are as follows:
- Giving the wrong diagnosis.
- Prescribing the wrong medication.
- Administering the wrong medication.
- Giving the incorrect dosage of drugs.
- Taking medications without the right guidance from the physician.
To learn more, check out our article on 6 Common CNA Mistakes to Avoid: A Comprehensive Guide.
What are common mistakes in nursing documentation?
Some of the common charting errors in nursing are as follows:
- Failing to document prior treatments.
- Failing to record drug information.
- Recording on the wrong patient’s chart.
- Failing to record that medications have been administered.
- Improper abbreviations.
How can nurses improve documentation?
Some of the ways CNAs can improve the documentation process are as follows:
- Listen to the doctor with the utmost concentration.
- Memorize the abbreviations and make sure to use the right abbreviations when you record a patient’s details.
- Have a neat and readable handwriting.
- Cross-verify all the details in the patient’s chart with the patient and the healthcare team whenever required.
