B.S. (Bachelor of Science)
School of Nursing
Honors Capstone Abstract
Nursing is a profession that can take you to endless different directions, not just in the hospital. Some may decide to work in a clinic, a school, or even laser hair removal centers. Although the setting and workday are different, one thing remains the same: charting. Charting is an everyday, every patient requirement for all nurses. Although this is unarguably one of most important skills to learn before becoming a nurse, most nursing schools do not have a class dedicated specifically to charting. This can create many problems for newer nurses who lack the experience and knowledge of how to properly word your documentation to avoid legal trouble. The purpose of this project is to help educate nursing students and newer graduates on the proper way to chart, examples of common mistakes, and specific wording to avoid, ensuring they have all the tools necessary to start their career out strong in the healthcare field.
In order to properly address this topic, I devised a plan of action on how I would approach it. I will be writing a research paper with a detailed evidence-based manual to improve nurses’ documentation skills. For the first part of the paper, I will educate myself on the current standards of medical charting and documentation. After this I will examine real cases of malpractice involving nurses and documentation errors to determine any common theme or similar mistakes. After I conduct and write about the research, I will construct the evidence-based manual on important tips for medical documentation I have learned during this process. The final goal of this assignment is to improve or strengthen the knowledge of nurses, nursing students, or other medical professionals with the importance of proper medical documentation to improve patient outcomes, satisfaction, and protect them in possible malpractice claims.
While reviewing real life cases regarding malpractice and charting, three major themes stood out to me. A lot of the cases were based on incomplete documentation, inaccurate text, or transcription errors. Incomplete documentation refers to when the nurse does not chart as much as they should have for a given intervention performed. The charting was either lacking important details or follow up information. Inaccurate text regards false information that was placed in the patient’s chart. This could be vital signs that were not correct, or lab values that were mistyped. Transcription errors are referring to people reading the chart and not understanding the meaning of a documentation. This is commonly seen with shorthand and abbreviations or typing errors that led to devastating mistakes. Further in the document includes a table of rationales with examples of these errors.
Bradshaw, Charlotte J., "The Importance of Charting and Documentation in the Nursing Profession" (2023). Honors Capstones. 1473.