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3 Common Nurse Charting Mistakes to Avoid (Part 1)

Accurate and complete patient chart information is essential to providing the highest possible standard of care. Here are simple tips to improve nurse charting, protect patients from treatment error and prevent potential malpractice liability.

Responding to questions in a pre-trial deposition.

This video can help you be prepared. 

Test Your Liability IQ: Top Reasons Nurses Get Sued

This webinar explores indemnity and expense payments for professional liability claims on behalf of nurses, RN, LPN and LVNs, insured under the CNA/NSO program during the most recent five-year period, 2011-2015.

Educator Toolkit: Documentation for Nurses 

Accurate documentation is a critical component of patient care. With materials in this section, you can help raise your students' awareness of documentation risks that can lead to claims of negligence and malpractice, and that by improving the quality of documentation, they can see fewer malpractice incidents.

Nurse Practitioner Case Study: Alleged improper admission orders resulting in morphine overdose and death.

The decedent patient (plaintiff) was a 72-year-old woman who had been receiving hospital care for acute back pain resulting from a fall. Her past history included chronic pain management and end-stage renal disease for which she received hemodialysis.

Nurse Case Study: Failure to adequately assess and monitor the patient post operatively resulting in the patient’s death.

The decedent/ plaintiff was a 67-year-old male who underwent a right total knee replacement. Following the procedure, the plaintiff was treated in the post-anesthesia care unit where an epidural catheter was inserted for post-operative pain management.

Nurse Case Study: Failure to prevent and properly treat decubitus ulcer.

Failure to prevent and properly treat decubitus ulcer – continues to Stage IV – defense verdict. 

Nurse Case Study: Failure to report changes in the patient's medical condition to practitioner.

The patient was a 38-year-old female admitted for a Cesarean delivery of twins. The babies were delivered without incident, but the patient experienced excessive post-operative vaginal bleeding attributed to placental accreta.

Nurse Case Study: Failure to timely diagnose and treat stroke.

Failure to timely diagnose and treat stroke – partial paralysis of arm, aphasia, mild cognitive impairment and foot drop – $4 million settlement.

Nurse Case Study: Incorrect IV push of potassium chloride.

Potassium chloride by IV drip ordered for woman, but family claims IV push of potassium chloride given – death – $250,000 verdict.

Nurse Case Study: Malfunctioning hospital bed blamed for strangulation death of man.

Malfunctioning hospital bed blamed for strangulation death of man – $1 million settlement in Texas with some parties – confidential settlement with others. 

Abbreviations in Documentation: A shortcut to disaster for Nurses

Trying to save time by using abbreviations? Make sure that you aren't putting yourself or your patients in jeopardy.

Administer meds without a doctor's order? Proceed with caution.

Registered nurses generally should administer medications only with a physician’s order. Only certain advanced practice nurses have prescriptive authority, and their qualifications, as well as the type of drug and the amount they are allowed to prescribe, vary from state to state.

How documentation could come back to haunt you.

The confusing or opinionated words you choose in charting today could come back to haunt you tomorrow.

Charting by exception: the legal risks.

There are numerous variations to charting by exception. Virtually every facility that uses such a system does it differently.

Defensive Documentation: Steps Nurses Can Take to Improve Their Charting and Reduce Their Liability

Whether you are an experienced nurse or recent grad, documentation can be challenging. Here is some information that can assist with improving your charting and reducing liability risks:  

Documentation on trial: 9 ways to protect your agency.

In most states, a patient can wait several years to file a lawsuit and then it can take years before the suit goes to court.

Documentation: proactive prevention of litigation.

There is no quick and effective antidote to malpractice allegations. Prevention, however, is necessary.

Don't cross the line: respecting professional boundaries.

At best, nurses and patients develop a special bond based on trust, compassion, and mutual respect.

Do's and Don'ts of Documentation

Good documentation can help nurses defend themselves in a malpractice lawsuit, and keep them out of court in the first place. 

Keeping up with technology: your risks and responsibilities.

Information technology is constantly evolving. Among the most common types are electronic health records (EHRs) and computerized physician order entry systems (CPOEs).

Nurse Fatigue Creates a Dangerous Environment

Nurses work long hours and play a critical role in keeping patients healthy. Many nurses feel that fatigue “comes with the territory” of such a high-stress, high-impact job. But what’s really at risk when a nurse is fatigued? 

Are You Filing Incident Reports Properly?

Knowing when—and how—to file incident reports can help you to protect yourself, your patients, your colleagues, and your organization.   

Educator Toolkit: Documentation for Nurses 

Accurate documentation is a critical component of patient care. With materials in this section, you can help raise your students' awareness of documentation risks that can lead to claims of negligence and malpractice, and that by improving the quality of documentation, they can see fewer malpractice incidents.

Nurse Case Study: Failure to report changes in the patient's medical condition to practitioner.

The patient was a 38-year-old female admitted for a Cesarean delivery of twins. The babies were delivered without incident, but the patient experienced excessive post-operative vaginal bleeding attributed to placental accreta.

Educator Toolkit: Documentation for Advanced Practice Nurses

Help raise your students' awareness of documentation risks that can lead to claims of negligence and malpractice, and show them that by improving the quality of documentation, they can see fewer malpractice incidents.

Educator Toolkit: Communication for Nursing Professionals

Clear, effective communication is vital for a nursing professional, especially when it involves patients, families, coworkers, supervisors and others. In this section, you can help improve your students' awareness of the critical nature of verbal and non-verbal communication, with particular emphasis on hand-offs, chain of command, disclosure, treatment, social media and more.

Educator Material Request Form​​​

NSO has developed an Educator Program to make it easy to receive case studies, articles and claim reports to use in your classroom. Sign up to join our educator program below!

Medical Malpractice 101 for Nursing Students: Know the Facts, Know Your Risk

What do nursing students need to know about medical malpractice? What should nurses know about their professional liability risks?

Nurse Practitioner Professional Liability Exposure Claim Report: 5th Edition

This Nurse Practitioner Claim Report, released by NSO and CNA, reports that the average total incurred of professional liability claims is $332,137 in 2022. 

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