ChartFlow Team
In every school you’ll hear the mantra “If it’s not in the chart, it didn’t happen.” But what should be in the chart? When should it happen? In this blog, we discuss the legal implications of medical and charting errors as well as explaining what mistakes to avoid and what is considered falsification of information.
Here are a few things every healthcare student should know before using an EHR for nursing notes, physician orders, or basic patient charting.
1) An EHR/EMR is a legal document.
If you falsify information, you can be fired, sued, and/or have your health related licenses revoked. Common accidental falsifications to avoid: Never record vital signs that were copied from a previous reading instead of taking them yourself. Never claim that you completed a task that another employee did.
2) If it’s not in the chart, it didn’t happen.
Nurses are taught this from day one of their education, but it applies to all healthcare professionals. If you provide any type of patient care but don’t record it in the patient’s chart, you and/or the supervising provider will face legal consequences if that lack of charting results in a medical error. For example, if you don’t chart a patient’s refusal of pain medications, and that patient then sues for withholding pain medication, you will not have any legal ground to stand on. Even worse, if you do not chart a medication as ‘given’ immediately after administering it, and a second dose is given by a different nurse or healthcare worker, that can result in a fatal overdose due to a lack of documentation in the Medication Administration Record (MAR).
3) Only view and enter data in relevant fields.
If you are responsible for taking a patient’s blood pressure, but the chart has fields for temperature and weight as well, only fill in the field for blood pressure. Never enter made-up information in fields unrelated to your task. If the EHR your facility uses requires entry in a field you are not responsible for, ask your supervisor what sign or symbol they use to represent “not applicable” or ask if there’s a way to override the EHR requirement in that section.
Additionally, do not view past visits in a patient’s chart if it’s not relevant to your job. For example, if you’re cleaning a wound as an ER Tech, you would have no reason to search that patient’s chart for past mental health visits. This would violate the patient’s privacy unless past history is directly relevant to your task and role.
4) Chart what you’ve done only after completing the task.
Never chart what you plan to do before completing the activity. For example, if you record a medication as “given” when preparing your medications for the day but don’t actually administer that medication until an hour later, that would be considered falsifying information. Wait until after you’ve given the drug to complete your charting. From a practical perspective, this makes sense. What if you chart a routine med pass when preparing a patient’s pills and then you have to assist with a code blue? Those medications may need to wait for a while, but the chart will not reflect that delay since you mistakenly entered the information before completing the task.
5) Never chart under another person’s login.
You should never login to an EHR or EMR with another person's username and password. Always use your own login and document who did an action if it was not yourself. If you cannot login, contact technical support for your facility’s EHR system.
6) Always sign off when you leave a computer so someone does not chart under your name.
If you follow these tips, you should avoid the major pitfalls of new healthcare workers using EHRs.
The best way to get used to charting, is practice! That’s why we have several free student courses in ChartFlow’s educational EHR.
Log in, and practice entering information or exploring the different fields. Get used to clicking around in an environment that’s completely safe to make errors in. The only people who suffer if you do something wrong or get lost in the site is our support staff, all of whom are ready to get you out of any sticky situation.
👉 Free EHR Practice for EMTs
👉 Free EHR Practice for Medication Aides
👉 Free EHR Practice for Nursing Students
-The ChartFlow Team
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