How do you fix a documentation error?

How do you fix a documentation error?

In Brief

1. Don’t obliterate the mistaken entry.
2. Make the correction in a way that preserves the original entry.
3. Identify the reason for the correction.
4. Follow facility policy when adding late information.
5. Never alter words or numbers after you’ve written them.
6. Correct mistakes promptly.

What is a documentation error?

Here are some of the top 9 types of medical documentation errors: Sloppy or illegible handwriting. Failure to date, time, and sign a medical entry. Lack of documentation for omitted medications and/or treatments. Incomplete or missing documentation.

How can medical record errors be prevented?

Tips for preventing medical errors

1. Keep your team well informed. By using electronic health records, your health care team will have a clear understanding of exactly what needs to be known about a certain patient.
2. Encourage your patients to ask questions.
3. Perfect your handwriting.
4. Communicate post-hospital plans.

How can nurses improve documentation?

Tips for Great Nursing Documentation

1. Be Accurate. Write down information accurately in real-time.
2. Avoid Late Entries.
3. Prioritize Legibility.
4. Use the Right Tools.
5. Follow Policy on Abbreviations.
6. Document Physician Consultations.
7. Chart the Symptom and the Treatment.
8. Avoid Opinions and Hearsay.

How can we avoid the most common nursing documentation errors?

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?

What should you do if you have a documentation error?

If your facility uses electronic documentation, strictly adhere to guidelines and procedures for correcting documentation errors in that format. Follow these pointers to correct a handwritten chart: Don’t obliterate the mistaken entry.

Who are the authors of medical error reduction and Prevention?

Review In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. 2021 Jan 4. Authors Thomas L. Rodziewicz 1 , Benjamin Houseman 2 , John E. Hipskind 3 Affiliations 1Michigan State University COM 2Memorial Healthcare System 3Kaweah Delta Medical Center

When to use ” mistaken entry ” or ” void ” in a document?

To avoid confusion, write “mistaken entry,” “delete,” or “void” instead. Whatever word or term you choose, use it consistently and make sure it conforms to your facility’s policies and procedures. If your facility uses electronic documentation, strictly adhere to guidelines and procedures for correcting documentation errors in that format.