The move by the state agency to fine a nursing care facility due to spelling and grammatical errors made by the staff with the charting of patient care was an appropriate measure.
This is so because of the critical role that documentation plays in ensuring that quality health care is administered to patients. To begin with, the records of patients are legal documents. This means that the documents can be used in legal proceedings. Secondly, if an occurrence or observation is not charted, then it is considered not to have happened. Charting is also important in the health care industry. In this case, the basic standards of care dictate that any health practitioner should understand a chart that has been charted by another colleague. In this case, they should be able to interpret the condition of the patient and his/her care correctly. Another important aspect of documentation with regards to patient care is that the document is used in financial reimbursement.
The document is evaluated by third parties to ascertain the viability of compensation. Another key factor to consider is the legality of patients’ records. They may be used as a basis for entering a law suit against malpractice. An expert in this case reviews the document and ascertains its quality and the appropriateness of care administered to the patient (Iyer, Levin, Shea and Ashton 16). Following the reasons highlighted above, it can be noted that the charting of patient care is very vital in health care provision. Therefore, it should be conducted in a systematic, organized, and coherent manner and should reflect the true state of the patient. Having a medical record that is accurate is the best defense that any nurse can have.
Having records that are not grammatically correct or have spelling errors can have serious implications. Wrong documentation can endanger the life of the patient. It may lead to overdosing patients. This has been the case with a lot of diabetic patients who are often given overdoses of insulin due to wrong charting.
Furthermore, the document may be misinterpreted by different people and may lead to confusion, and in case of any mishaps, the facility may be sued or the nurse responsible restricted from practicing (“Nursing Know-How: Charting Patient Care”, 4). If I was the manager of a facility that has had problems with nurses charting wrongly, I would take precautions to ensure that charting is done correctly. In the case of nurses making spelling and grammatical errors, the nurses may be making these errors due to charting speedily. I would carry out a sensitization program where the nurses are sensitized on the importance of taking their time to chart so as to avoid unnecessary errors. If some of the errors are due to the nurses failing to know the correct spelling or grammar to use, then the facility can organize a part time training for nurses with difficulties in grammar. This will help them improve their grammatical skills. They can also liaise with their colleagues to assist them in that area (“Nursing Know-How: Charting Patient Care”, 7). Proper documentation should be accurate and void of any vagueness.
This will depict a clear picture of the patients’ condition. A good chart should include only information that is objective. This means that a nurse should write what he/she can smell, hear, feel and see among others. Charting should also be done in a legible manner where others are able to read what is written. In the case where an individual cannot read a chart done by another nurse, the individual should inquire from the person who wrote it instead of making assumptions that may endanger the patients’ life.
Other things like ensuring the recording is done on the correct chart and charting immediately after each care is given are also important (Iyer, Levin, Shea and Ashton 18).
Iyer, Patricia W., Barbara J. Levin, Mary A. Shea, and Kathleen Ashton. Medical Legal Aspects of Medical Records.
Tucson, AZ: Lawyers & Judges Pub. Co, 2006. Print. Nursing Know-How: Charting Patient Care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009.