Nursing documentation: How to avoid the most common medical errors

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.

What are EMRs in nursing education?

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.

Medical documentation errors impacting patient outcomes

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.

Top 9 types of medical documentation errors

Here are some of the top 9 types of medical documentation errors:

1. Sloppy or illegible handwriting
2. Failure to date, time, and sign a medical entry
3. Lack of documentation for omitted medications and/or treatments
4. Incomplete or missing documentation
5. Adding entries later on
6. Documenting subjective data
7. Not questioning incomprehensible orders
8. Using the wrong abbreviations
9. Entering information into the wrong chart

Take #1 above, for example - sloppy or illegible handwriting. This can lead to a patient care provider receiving mixed messages about the patient's history and directives. Some common transcription mistakes, for example, include typing “hyper" instead of “hypo," or vice versa, or typing “she" instead of “he." A wrong diagnosis can get embedded in a patient's chart and not only affect their care, but the error can affect when that patient changes insurance companies and a pre-existing condition is noted.

Also, a combination of the above common nursing and medical documentation errors can also lead to medication errors. Consider this: every day, at least one death in the U.S. happens a result of a medication error, and approximately 1.3 million people annually are injured due to medication errors.

The impact of EHR technology on nursing workload 

Nurses face more challenges today than ever, and, on top of increasing patient care demands, they must adapt to new technology to help them handle the workload. It is incumbent upon nursing schools to ensure tomorrow's nurses are adequately trained on EMRs. If nurses aren't comfortable with and proficient in the technology when they encounter EMRs or EHRs on the job, chances for nursing documentation error skyrockets.

For example, in 2012, a study that looked at how new nurses assess their knowledge and skills compared to how nursing managers view those same skills in short-term clinical settings revealed gaps in 13 of 28 knowledge and skill areas considered critical to effective EMR/EHR use. That study also found:

• 90% of new/novice nurses and 75% of nurse managers reported participating in EHR training at their jobs.
• Only 20% of new/novice nurses and a mere 7% of nurse managers said EHR was a part of their curriculum during nursing school.
• Over 60% of nurse managers agreed it took new nurses more than 2 months to be proficient using EHRs.

That study also identified 13 skill areas as “gaps" in nursing documentation. They include:

• Spreadsheet development
• Data entry
• Medication administration
• Documentation
• Treatment documentation
• Graphics documentation and tracking
• Patient education material retrieval
• Patient education documentation
• Lab results retrieval
• Diagnostics results retrieval
• Accessing electronic charts contents
• Accessing prior admission data
• Care plan development and updates
• Discharge planning documentation and updates

In other words, a lot of hours - and money - is being spent to put nurses through EMR training on the job, when they could be spending that time focusing on giving quality patient care.

How can EMR academic training reduce nursing documentation errors?

Proper and accurate documentation is essential to avoid types of nursing documentation errors, and for helping to avoid patient deaths or increased liability for the caregiving facility, physician, or nurse. This is where EMRs come in, and where effective EMR training of nursing students can play a vital role.

With the use of academic EMRs, nursing instructors can properly educate their nursing students on the technical competencies of an EMR, as well as the critical thinking skills needed to provide safe, effective care. With academic EMRs such as Lippincott's DocuCare, nursing students will be able to learn early in their education the ins and outs of proper medical documentation. Good and effective documentation is:

• Accurate
• Factual
• Complete
• Timely
• Organized
• Compliant with health laws and facility standards

Academic EMRs benefit nursing students in preventing medical documentation errors before entering into real-world practice. Students have shared that the use of academic EHRs improved their charting performance, critical thinking skills, and preparedness for practice after graduation. Instructors benefit too, and say that using an academic EMR - Lippincott DocuCare, in particular - allowed them to provide immediate feedback to students and help students to further develop clinical reasoning skills as well as clinical skills.

Lippincott DocuCare enhances clinical learning by contextualizing realistic patient care scenarios with hands-on documentation. Its intuitive educational experience lets you interact with your students, track their progress, and focus your teaching strategies using evaluation tools, pre-populated cases, and a unified simulation experience. DocuCare includes more than 200 assignable, true-to-life patient scenarios covering a wide range of diagnoses and demographics - from medical-surgical to mental health to maternal-pediatric and beyond - appropriate for all levels of nursing. This academic EMR also offers clinical decision-making for your entire curriculum: discuss case studies and care plans in the classroom, add realism to the simulation lab, create privacy-protected patient records in clinical, incorporate informatics competencies required for Quality and Safety in Nursing Education (QSEN) standards, and much more. Plus, the platform is customizable and can be tailored to your exact instructional needs.