Nurses and Documentation Errors

Documenting vital information about a patient's condition, treatment, and other elements of their care is often among a nurse's responsibilities. However, nurses are human beings. They can make mistakes.

That might not necessarily stop a patient or other such party from taking action against a nurse when documentation errors occur. Depending on the circumstances, documentation errors could even jeopardize a nurse's license.

Are you facing license suspension, revocation, or similar disciplinary action because of alleged documentation mistakes? If so, enlisting legal help is a wise idea at this time.

Attorneys with our Professional License Defense Team at the Lento Law Firm are available to help you protect your career. Get started on your defense today by contacting us through our online form or calling us at 888-535-3686.

Common Types of Documentation Errors in Nursing

Documentation errors can occur for many reasons and can take many forms. Again, nurses are people. Some errors are simply human mistakes.

Others may be the result of the following:

• Not documenting critical information: Nurses sometimes make errors because they don't document information or data they should document. To guard against accusations of misconduct, a nurse may want to document more information and data than they believe is necessary. Too much documentation is rarely as significant a problem as too little.
• Poor handwriting: It may seem unfair to call an otherwise qualified nurse negligent or careless because their handwriting isn't pretty. However, poor handwriting can result in confusion that may negatively impact patient care.
• Failure to date/sign/time entry: A nurse may vigilantly document all the information and data they should for a given patient. They may still commit an error if they forget to date, sign, and/or mark the time when completing an entry.
• Incomplete documentation: Lack of thoroughness is a common cause of documentation errors. Medical documentation must include all critical pieces of information to serve its purpose.
• Not documenting changes in treatment: A nurse may properly document the initial treatment a patient receives. If the patient changes treatment, particularly if they do so relatively soon after starting their initial treatment plan, a nurse may forget to document the change. As a result, a doctor or other health care professional who begins treating the patient may rely on old documentation, potentially endangering the patient or slowing their recovery.
• Using incorrect abbreviations: Nurses and medical professionals, in general, often rely on abbreviations when documenting patient information. Confusion can occur when a nurse accidentally uses the wrong abbreviations.
• Transcription errors: Medical documentation frequently involves transcribing recordings. Thus, transcription errors are among the most common types of documentation errors in nursing.
• Inconsistent documentation: Documentation errors can involve gaps or inconsistencies in the way a nurse documents patient information. For example, perhaps they document some treatments but not others. Or, maybe they add entries later on instead of documenting important information in real-time. Even using inconsistent terminology can lead to confusion among others involved in a patient's treatment.
• Not documenting consent: Medical facilities and health care workers must typically receive patient consent before providing treatment. Failure to properly document a patient's consent could result in legal issues.
• Lack of clarity: It's essential that everyone involved in a patient's care is able to read and understand the information in their chart. Unclear or ambiguous documentation can influence patient outcomes.
• Documenting subjective impressions: Nurses need to strike a delicate balance when documenting patient information. They need to provide thorough information while ensuring they only document that which is objective and verifiable. An error may occur if a nurse includes their own subjective impressions about a patient's condition or treatment in official documentation.
• Using the wrong chart: A documentation error may happen if a nurse enters information into the wrong chart. This type of mistake may be more likely to occur at a busy facility.
• Copying and pasting: The increased reliance on electronic health records (EHRs) and electronic medical records (EMRs) throughout the medical field has resulted in greater convenience for health care professionals. That said, it's also made it extremely easy to repopulate new patient records with old information via copying and pasting. While this method may save time, it can also result in omissions, inaccuracies, etc.
• Typos: Seemingly minor typing errors can have major impacts on patient documentation. For example, a tired nurse might accidentally type “hypo” when they mean to type “hyper” (or vice versa). Even accidentally switching the order of numbers can theoretically have adverse consequences for patients.
• Fraud: Not all medical documentation “errors” are actually mistakes. Some health care professionals engage in fraud by intentionally altering patient records for various reasons. Although there are exceptions, an accusation of fraud is usually more serious than an accusation of negligence or carelessness.

If a nurse makes a documentation error, it's helpful for them to fully understand it. Knowing what type of error you made can help you avoid making similar mistakes going forward.

In the meantime, you may need a defense if a documentation error has caused someone to file a complaint against you. Our Professional License Defense Team at the Lento Law Firm is available to assist during what may be a challenging time in your career.

Charting Errors Can Have Serious Consequences

Proper documentation is critical in a medical setting. Research from Johns Hopkins University indicates medical error is the third-leading cause of death in the US. Accurate documentation and patient charting can guard against mistakes that could put patients at risk.

This is among the many reasons nurse licensing boards take accusations of documentation errors seriously. If you've been accused of a documentation error, you should take the matter seriously as well. Be proactive and defend yourself by reviewing your case with our Professional License Defense Team at the Lento Law Firm sooner rather than later.

How Common Are Documentation Errors in Nursing?

There's no official answer to the above question. Various studies arrive at different conclusions regarding the rate of medical documentation errors in the US.

Some experts estimate that approximately 70 percent of patient charts contain at least one error. Another study indicates that at least 43 percent of patient charts contain mistakes.

It's clear that documentation errors in the medical field aren't uncommon. Understanding why they happen can help nurses and their colleagues guard against such mistakes.

Why Nurses Make Documentation Errors

Many potential factors can cause nurses to make documentation errors that could put their licenses at risk. Common examples include:

• Insufficient staffing: Virtually any professional in any line of work may be more error-prone when their bandwidth is stretched. According to research, medical documentation errors became particularly common in 2020, when nurses and health facilities in general were overstressed due to the COVID-19 pandemic. Such findings indicate that staffing shortages may contribute to nursing documentation errors.
• Distraction: Properly documenting patient information often requires focus. Errors can occur when nurses try to input patient information in settings where distractions may abound, like a busy emergency room.
• Lack of training: Nurses who haven't received proper training are naturally more likely to make mistakes than those who have. In the digital age, when medical documentation often requires using various apps and software, thorough training is more essential than ever.
• Communication issues: Medical documentation sometimes involves taking down information someone else (such as a doctor or patient) has verbally communicated. Communication issues and misunderstandings can thus result in errors. For example, perhaps a patient informs a nurse that they take a particular medication. Several medications have names that sound similar to one another. Thus, a nurse may put the wrong information in a chart because they misunderstood what a patient told them.
• Manual documentation: Digital medical documentation has its limitations. Generally, though, researchers have found that manual documentation is among the more significant factors contributing to errors. Nurses and their colleagues can guard against errors by agreeing to use the same documentation method and format consistently across all patients.

It's also worth noting that nurses are by no means the only health care professionals who may be involved in documenting a patient's history, condition, treatment, etc. A documentation error could be the result of someone else's mistake.

We may consider this factor if it appears relevant to your case. At the Lento Law Firm, our Professional License Defense Team will thoroughly account for any factors that may strengthen your defense.

How Documentation Errors Can Jeopardize a Nurse's License

Documentation errors can lead to several potential consequences. If a patient is harmed or doesn't receive the treatment they need due to an error, they may file a medical malpractice lawsuit.

A nurse usually won't be the direct subject of a lawsuit or insurance claim. Usually, their employer will be the target. If they're able to reach a settlement, the insurance company will pay the claimant. Regardless, making an error that triggers a lawsuit could put a nurse's career at risk.

In addition, patients, colleagues, and others can typically file complaints against nurses they believe to be responsible for errors. The process for doing so varies from one state to another. A general overview of what the process may involve is as follows:

• Initial complaint or report: Someone files a complaint with the relevant state agency or department. Although this isn't always the case, they're often able to do so anonymously. Sometimes, the law may even require certain individuals to file reports when they suspect nurses of making mistakes that could endanger patients. Although there are exceptions, those making complaints or filing reports against nurses are often protected from civil liability if their allegations prove to be false.
• Evaluation: Once more, the process varies on a state-by-state basis, but it's not uncommon for the relevant state department or agency to begin by evaluating the basics of a complaint before taking further action. A complaint or report might be dismissed if an initial evaluation suggests the nature of the alleged misconduct doesn't warrant further investigation.
• Referral: Sometimes, a person filing a complaint or report about a nurse potentially responsible for documentation errors may directly contact the board or agency that oversees nurse licensing in the state. If they don't, the agency or department that receives the initial complaint may refer the case to the appropriate board or agency.
• Investigation: An investigation will typically ensue when the state board or agency supervising nurses receives a complaint that warrants further review. If the allegations against a nurse are serious, their freedom to practice nursing could even be limited during the course of the investigation. Although such investigations aren't criminal cases, if investigators find evidence of criminal wrongdoing (unlikely in a documentation errors case), they may contact law enforcement accordingly.
• Negotiation: While these types of cases aren't criminal cases, the overall process can involve some elements reminiscent of criminal cases. For example, someone facing criminal charges may bargain or negotiate with the district attorney for a plea deal. This typically involves entering a guilty plea in exchange for more lenient sentencing than they'd otherwise receive. Similarly, in many states, nurses facing disciplinary action due to complaints can negotiate with investigators or nursing board officials, accepting some form of disciplinary action while admitting at least some fault. It often helps to have lawyers on your side when such deals are on the table. Although attorneys can't force you to make a particular decision, they could help you better understand whether accepting such a deal is wise.
• Hearings: Nurses who've had complaints or reports filed against them often have the opportunity to participate in hearings. As with criminal cases, these hearings involve investigators or other such parties presenting the evidence against a nurse. The nurse may also have the chance to defend themselves against accusations during a hearing. Depending on the specifics of the process in a given state, a nurse might also have the option of requesting a hearing after disciplinary action has been recommended.
• Final determination: As always, the exact way the process concludes is different across every state. It often involves investigators presenting their findings to board officials. Their findings may also include disciplinary action recommendations. Regardless, once the investigation concludes and the relevant board or agency members receive the information, they will make a decision regarding whether disciplinary action is necessary, and what type of action to take if so.
• Appeal: State licensing board rules usually allow a nurse to appeal a board's decision when it decides to take disciplinary action against them. However, a nurse may only have a limited time to file an appeal. Don't delay if you wish to appeal the outcome of your case.

The point in the process when a nurse learns about a complaint someone has filed against them varies across jurisdictions. Any nurse who learns that someone has filed a complaint against them should strongly consider reaching out to attorneys as soon as possible.

Navigating this process alone can be an overwhelming experience. By enlisting the help of our Professional License Defense Team at the Lento Law Firm, you'll have experienced attorneys by your side every step of the way. We'll ensure your rights are protected throughout an investigation.

Common Forms of Disciplinary Action in Nursing Documentation Errors Cases

The nature of the misconduct, the state where it allegedly occurred, and other such factors can influence the types of disciplinary action a nurse may be subject to when investigators determine they're responsible for errors. Some forms of disciplinary action nursing boards may consider include:

• License suspension
• License revocation
• Probation
• Requiring a nurse to participate in drug counseling, alcohol counseling, or a similar program
• Requiring a nurse to participate in continuing education programs to address gaps in their skills or knowledge
• Requiring a nurse to work under the supervision of another nursing professional

Many forms of disciplinary action are temporary. For example, a probationary period won't last forever.

Understanding the consequences you may face when someone files a complaint is important during an investigation. If a nursing board or similar licensing board decides to take disciplinary action, you also need to understand how their decision affects your rights, responsibilities, and privileges. Our attorneys at the Lento Law Firm's Professional License Defense Team will gladly explain any of these topics if you ever have questions during your case.

How a Complaint About Documentation Errors Can Affect a Nurse's Ability to Practice in Other States

A nurse may lose the privilege to practice in their state if a complaint leads to disciplinary action. Even if they only lose this privilege temporarily, the impact of not being able to practice nursing for a period of time can have dramatic implications for their career.

Unfortunately, disciplinary action taken in one state could also potentially jeopardize a nurse's ability to practice nursing in other states. That's because most states throughout the country now participate in the Nursys system.

Nursys is an information-sharing program and system that theoretically offers several benefits to nurses. For example, a nurse licensed in one state that participates in the program may be able to practice in another Nursys state without having to go through the licensing process anew.

Unfortunately, the Nursys system can also limit a nurse's freedom to practice elsewhere if they're subject to disciplinary action. Typically, when a licensing board in a Nursys state takes disciplinary action against a nurse, the board will record an entry in the Nursys database.

Potential employers in other Nursys states can access this information. As a result, there may be few places in the nation where a nurse can find a job if a licensing board disciplines them after someone files a complaint.

This doesn't have to happen to you. While no legal professional can ethically promise a specific outcome to your case, our Professional License Defense Team at the Lento Law Firm can offer the defense you need when the threat to your career is so prominent.

Guarding Against Documentation Errors as a Nurse

The following tips may not help you prevent errors that have already occurred. That said, knowing how to guard against documentation errors can reduce your chances of being the subject of future complaints.

Strategies to limit or prevent documentation errors include:

• Double-check: It's a simple recommendation, but a critical one. If you make a point of double-checking your work every time you document patient information, you'll be more likely to catch errors before they cause problems.
• Follow procedures: It's not entirely a nurse's responsibility to ensure no documentation errors are made. A nurse's employer should take steps to prevent errors by implementing thorough training and establishing clear documentation procedures. However, a nurse can do their part by carefully and consistently following all procedures that may be in place.
• Ask for clarification: Never record information if you're not sure you properly heard or received the information. If you ever have a question about information you've received from a patient, doctor, lab, or other such party, always ask for clarification before putting that information in a patient's chart.
• Don't take shortcuts: Digital tools can help you save a lot of time when recording patient information. Just don't use them as a crutch. Copying and pasting information from one form onto another may help you complete the task more quickly than you otherwise would, but it could lead to greater frustrations in the long run if a shortcut results in an error.
• Use clear language: Some usage of medical jargon and abbreviations is acceptable in medical documentation. However, you must consider all the potential parties who may be reviewing a patient's chart. Including unclear jargon or abbreviations could lead to patient treatment errors if someone reading a chart isn't familiar with the language you've used.
• Document communications: Informal communications with a patient or their loved ones can include information that should go down in a patient's chart. At the very least, it's smart to document most (if not all) communications with patients, their families, and other such parties. Doing so can guard against confusion and miscommunication.
• Document all forms of care: Some health care professionals mistakenly assume it's unnecessary to document routine or minor care. Don't make this error. Documenting all care a patient receives ensures thoroughness and accuracy.
• Check the law: Your state likely has a Nurse Practice Act or similar law on the books. This statute may provide information about your duties and responsibilities as a nurse. Review the law thoroughly. Familiarizing yourself with your legal rights and responsibilities can help you better appreciate what types of information you do and don't have to document.

These are among the most effective ways to prevent documentation errors from occurring in the first place. If you've already been the target of a complaint accusing you of documentation errors, enlisting professional legal assistance is among the top ways to protect yourself and your future.

Potential Defenses When a Nurse is Accused of Documentation Errors

The best defense strategy for a nurse accused of documentation errors will vary depending on the details of the case against them. The following are a few common defenses lawyers may employ in this type of case:

• Someone else made a mistake: Sometimes, a nurse may accurately take down the information they receive when documenting a patient's condition, history, or care. However, the source of the information may have erred in a way that led to an inaccuracy. For example, a nurse documenting a patient's care may correctly input lab results. This information may not technically be accurate if a mistake was made at the lab itself.
• Someone provided false information: A nurse may also put the wrong information down on a patient's chart because, for various reasons, someone else may lie to them. Perhaps a patient feels embarrassed about something in their medical history. Thus, they might omit this information or lie about it when speaking with a nurse. Such an omission or lie could result in a documentation error that negatively affects a patient's care. While no one should ever accuse patients of deceit without strong evidence, this example merely serves as a reminder that the information a nurse documents can be erroneous or inaccurate if the source providing it isn't completely truthful.
• Procedures were followed: A nurse could correctly follow all documentation procedures according to their training and employer's policies. Regardless, an error or omission may occur if the procedure their employer requires them to follow is lacking in some capacity. In a case like this, an effective defense may involve showing how a nurse took all the correct steps required of them, and any fault lies elsewhere.
• Technical issues: A nurse may not be responsible for a documentation error. In some instances, perhaps no human is responsible for an error. Some errors could result from glitches, defects, or similar issues affecting medical documentation apps or software. While medical professionals must still check patient records for accuracy, in some cases, citing technical issues could guard against a nurse losing their license or facing similar consequences.
• The error was an isolated incident: There are cases when conceding that an error occurred may be the best defense strategy. Even if a nurse admits to making a mistake, they might avoid significant disciplinary action if they can cite their otherwise spotless record to illustrate how one error was an outlier in an otherwise impressive career.
• No error was made: The fact that someone has accused a nurse of a documentation error doesn't always mean the error actually happened. Often, investigators will discover when a complaint was made erroneously. However, just as nurses are human, so are investigators. A nurse or their attorneys may have to actively demonstrate how an alleged error isn't actually an error if investigators overlook critical details.

Mitigating factors can also influence a case's outcome. For example, perhaps a nurse is genuinely responsible for an error. Rather than denying responsibility, they've taken proactive measures (such as enrolling in training or continuing education programs) to address the issue and guard against future mistakes.

Licensing boards will often consider such mitigating factors when deciding what type of disciplinary action to take (if any). Remember, no attorneys can guarantee what a licensing board will or won't do.

Still, lawyers could advise you on how taking certain positive steps could bias a licensing board in your favor. Attorneys can also cite these mitigating factors during hearings to ensure those considering disciplinary action are aware of them.

In the end, the right defense strategy for one nurse may not be ideal for another. The attorneys with the Lento Law Firm's Professional License Defense Team thoroughly understand this. That's why we work hard to tailor our approach to the individual needs of each and every client.

Why You Need a Nursing License Defense Attorney When You're Accused of Documentation Errors

Legal professionals can assist in many ways when a nurse faces disciplinary action for alleged documentation errors. Ways we may help you defend your rights include:

• Helping you properly respond to a notice of a complaint
• Handling any administrative tasks your case may involve, such as completing paperwork
• Identifying weaknesses in the case against you
• Gathering evidence and reviewing it carefully for factors that could strengthen your case
• Coordinating with witnesses
• Representing you during hearings, interviews, and other stages of the investigation
• Ensuring you thoroughly understand your responsibilities during an investigation
• Explaining whether negotiating or accepting a settlement with the licensing board is a good idea
• Explaining to the board why disciplinary action should be lenient based on your professional history, mitigating factors, etc.
• Assisting you with an appeal, which may be an option in your state
• Explaining what you should and should NOT do during an investigation, helping you avoid mistakes that could otherwise exacerbate the situation
• Explaining your rights at all stages

That's by no means a complete list. What's most important now is that you act fast. The sooner you begin working on your defense, the better.

It can be very stressful when someone files a complaint accusing you of documentation errors. You've worked hard for your career. You don't want to worry about potentially losing it because of someone's allegations.

At the Lento Law Firm, our Professional License Defense Team offers the peace of mind that comes from knowing experienced and qualified attorneys are handling your case. Protect your career by submitting our online contact form today or calling our offices at 888-535-3686.