The "big 8" charting mistakes

Errors or omissions in your charting, even if seemingly harmless, not only could impact patient care, but could also undermine your credibility in court. Be careful to avoid these common documentation errors:

1. Omissions. Include all significant facts that other health care team members will need to care for the patient. Otherwise, a court may conclude that you failed to perform an action missing from the record or tried to hide evidence.
2. Personal opinions. Don't enter your personal comments or opinions. Record only factual and objective observations and patient statements.
3. Vague entries. Instead of "Patient had a good day," state why: "Patient denied having pain."
4. Late entries. If you have to make a late entry, identify it as such and sign and date it. Note the date and time you're relating back to.
5. Improper corrections. Never erase or obliterate an erroneous entry. Instead, follow your facility's policy and procedure for correcting documentation errors.
6. Unauthorized entries. Only you should record what you did; don't document for anyone else.
7. Erroneous or vague abbreviations. Use only standard abbreviations approved by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and your facility.
8. Illegibility and lack of clarity. Write so others can read your entry. Use a dictionary if you're unsure of spelling or usage.

Source: NCLEX-RN Review made Incredibly Easy!, 3rd edition, Lippincott Williams & Wilkins, 2004.