If you are a California registered nurse or a licensed practical nurse, you need to know the increased risk to your nursing license associated with charting errors in nursing and charting requirements in an era where reduced staffing in today’s health care environments is the norm.
Charting errors are a classic reason that many nurses receive letters of inquiry from the Bureau of Registered Nursing (BRN). In many cases, these errors can be simply caused by one shift failing to document verbal orders in a patient’s chart when the new shift nurse takes over.
Common nursing charting errors include the following:
- Failing to record pertinent health or drug information
- Failing to record nursing actions
- Failing to record that medications have been given
- Recording in the wrong patient’s medical record
- Failing to document a discontinued medication
- Failing to record drug reactions or changes in the patient’s condition
- Transcribing orders improperly or transcribing improper orders
- Writing illegible or incomplete records
As a nurse, you can never assume that the person taking over your shift and patient load will accurately document verbal orders you transmit to them. You must take responsibility for this yourself to protect your professional license. If charting errors are detected in your patient’s record, you will be held accountable by the Bureau of Registered Nursing. And if you are later terminated, HIPAA regulations make it impossible to access patient records you might need to defend your nursing license by recreating the exact sequence of events in the health care setting. This becomes virtually impossible without access to these critical records.
Case in point: A Registered Nurse Monitoring A Patient Who Later Dies Is Investigated by the BRN
Nancy, a critical care nurse, was monitoring four patients in the critical care unit of her hospital. Her shift ends and later, one of the patients, David, she was monitoring, dies. During Nancy’s shift, she orally communicated the specifics of caring for David to her shift relief nurse but failed to document the specifics in David’s chart. The BRN is notified of the charting deficiencies in Nancy’s case and launches an investigation.
Today’s health care environments are continually challenged to cut costs and renegotiate labor contracts with nursing unions such as the California Nurses Association and National Nurses United. Increased cost cutting reduces staff-to-patient ratios in health care settings and puts licensed practical nurses and registered nurses at higher risk for similar situations of charting deficiencies and errors.
If you are a California nurse under investigation for a charting issue you need to contact an experienced licensing attorney immediately. A qualified licensing lawyer can subpoena records from the hospital which document the practices and procedures used by the hospital for staffing (the “employers standard of care”) in order to prove a pattern of under-staffing.
The Law Offices of Lucy S. McAllister have successfully represented a wide range of California licensed nurses and other licensed health care professionals and we are experienced in handling all types of licensing accusations and licensing issues in addition to criminal cases. Let us help you protect your professional license, your reputation, and your livelihood.