How do you legally correct an error a nurse makes in documentation?
Make the correction in a way that preserves the original entry. Draw a single line through the erroneous entry and write the time, date, and your name. Identify the reason for the correction. Include the rationale in your notation; for example, “mistaken entry, wrong medication name written.”
What is the proper procedure for documentation error correction?
Proper Error Correction Procedure
- Draw line through entry (thin pen line). Make sure that the inaccurate information is still legible.
- Initial and date the entry.
- State the reason for the error (i.e. in the margin or above the note if room).
- Document the correct information.
What recording and reporting should be done with medication errors?
It is important to record any medication incident in the client’s medical record. Incident reports must not be filed or attached to the client’s medical record. According to the Incident Severity Rating (ISR) of the incident, the District Manager or Manager on‐Call must be notified.
When an error has been made and you need to correct a medical record what must be done?
The idea is to make it very easy for your provider’s office to amend your records. Make a copy of the page(s) where the error(s) occur. If it’s a simple correction, then you can strike one line through the incorrect information and handwrite the correction.
Which criteria should nurse documentation Fulfil?
For documentation to support the delivery of safe, high-quality care, it should: Be clear, legible, concise, contemporaneous, progressive and accurate. Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes.
Why should nurses report medication errors?
Medication errors have significant implications on patient safety. These errors occur at all stages in medication use: ordering, prescription, dispensing, and administration. Error detection discloses those errors and thus, encourages a safe culture (Montesi & Lechi, 2009).