Importance Of Charting In Nursing

2.2 Incomplete charting, the use of uncommon abbreviations and falsified documentation Besides, not only the issue of unreadable handwriting, due to the lack of time and abundance nursing care and patients assignment, nurses are also prone to involve in incomplete charting. As we know that, there are many reports and charts need to be filled during one shift such as four hourly observation chart, pain assessment chart, input and output chart, Morse Fall Scale assessment chart and so on. Nurses tend to take everything for granted and document in simple way. For example, during input and output charting, nurses document for the quantity of urine output but he or she might miss to fill in the remarks column which required the nurses to document

Do nurses correctly know how to differentiate between objective and subjective data? Objective data are observable and measurable data obtained through observation, physical examination, laboratory and diagnostic testing while subjective data are information from the client's point of view including feelings, perceptions, and concerns. For example, a nurse writes “patient sleeps well last night”. In this context, “well” is treated as observable data. However, “well” is too broad to explain, not specific and can be questionable. What does it means by ‘well’? How well is the patient? Any score or to what extend the patient is well? Hence, in this case, nurse must understand on how to use the subjective and objective data clearly, be confident and know the patients thoroughly before chart down the patient’s progress or information. “Patient verbalizes that she or he can sleep well last night” is subjective data, straight forward, safer and understandable. Next, another common charting errors include failure to record nursing actions and medications given, record in the wrong patient’s medical record, failure to document a discontinued medication (College of Licensed Practical Nurses of Alberta,

An incomplete and falsified medical record demonstrates that care given was incomplete (Huston, 2006). Clearly, incomplete documentation in patient clinical records can contribute to inaccurate quality and care information. Not only that, patient may also take legal actions. Furthermore, it can cause a nurse to lose the license. There are consequences of inappropriate or inadequate documentation. A care provider could face loss of employment or suspension from his or her workplace. No doubt, there would be personal stress, possible loss of income and perhaps legal expenses. Since nurses are team of health care provider, one of the most serious situations could involve a severe injury or death of a client due to inadequate or inaccurate documentation. The use of uncommon abbreviation can also lead to undesirable impression and interpretations. Hence, it increase the chance of medical error. A study done in twelve government primary care clinics in Malaysia by Khoo et al. (2012) aimed to determine the prevalence and magnitude of medical errors reported that overall 98.0% of the medical records had some form of documentation problems. Approximately half of the medical records, there was no documentation of history, physical examination, presenting problem and