When it comes to nursing documentation, knowing how to accurately document a patient can literally mean life or death. Some of the most common medical documentation errors can also be the most disastrous. Plus, improper documentation can open up an employer to liability and malpractice lawsuits. For nurses, who are on the front lines of defense in the medical field, being adequately trained early on proper documentation can help avoid such medical errors, save lives and help protect their employers.
So how can we avoid the most nursing documentation errors, to ensure patients receive appropriate, and, possibly life-saving care? By ensuring our nursing students are getting the training they need on electronic medical records (EMRs) - also known as electronic health records (EHRs) - while still in school.
EMRs are a digital version of a patient's paper chart. They're easy to find, search, and update, and provide tools like reminders, alarms, and automated processes that improve clinical accuracy. U.S. healthcare organizations have been transitioning from paper-based medical records to electronic health records for over a quarter of a century. They allow organizations to minimize the high rate of medical errors occurring throughout the healthcare industry and act as a tool for increasing patient safety and decreasing the overall cost of healthcare.
By providing the EMR training software to these students to use in the classroom, they can practice various nursing simulation scenarios and become proficient in clinical simulation in a safe, guided environment overseen by an instructor.
Because the truth is that the majority of medical errors don"t occur as a result of incompetence or recklessness by nurses or healthcare staff. They occur due to faulty systems and fragmented processes - with faulty documentation being a main culprit.
Let's first take a deeper look at the problem.
Examples of medical documentation errors
One of the most famous cases in medical history that resulted in the regulation of the number of hours that resident physicians are allowed to work is also a case study in clinical documentation failures.
In 1984, a college student in New York, NY named Libby Zion was admitted to a Manhattan emergency room with a high fever and agitation. The ER residents on duty administered a sedative and painkiller. But what they didn't know was that the patient was taking an anti-depressant that made for a fatal combination with the drugs given to her in the ER. Zion died from cardiac arrest. Although EHRs and EMRs weren't around in 1984, this is still a lesson in the life-threatening dangers of not having accurate, up-to-date medical histories when treating patients.
And here's another case:
In Susan Meek. V. Southern Baptist Hospital of Florida, Inc. d/b/a Baptist Medical Center, the patient (plaintiff) was admitted to the hospital for a hysterectomy. She started bleeding after surgery and was admitted to the radiology unit for uterine artery embolization (UAE) in an attempt to stop the bleeding. The physician told the nurses to perform frequent leg examinations to mitigate the risk of diminished blood flow and nerve injury, but the patient claimed the exams were not performed. The patient suffered nerve damage after a massive clot was removed in the external iliac artery. We don't know whether the nurse(s) responsible for the patient actually did perform the ordered leg examinations, because the supporting documentation didn't exist. The patient sued, and the hospital had to pay her $1.5 million in damages.