As a nursing professional, your charting is equivalent to your word. It’s also a tool for protecting yourself and your license. If your charting is incomplete or not up to standard, it can lead to scrutiny from your employer and the California Board of Nursing.
Unfortunately, even the most diligent nurses can find themselves facing a nursing board investigation due to charting issues. Knowing what red flags the board looks for can help you protect your nursing license and reduce your likelihood of being the subject of an investigation. Here’s a closer look.
Why Thorough Documentation of Patient Records Matters as a Nurse
Patient records communicate critical information about patients and their conditions. They also serve as legal documents that demonstrate the care you provided or didn’t provide. When a patient’s chart contains inconsistencies or is missing information outright, it can trigger a nursing board investigation. You may provide excellent patient care, but that alone is not enough.
With that in mind, here are some charting red flags that the California Board of Nursing may scrutinize:
Incomplete Charting
One of the most common issues during an investigation involves incomplete charting. Suppose that your organization requires updated assessments every two hours. If you miss an assessment or fail to chart it, that can be a major red flag.
The occasional missed assessment isn’t going to be a significant problem on its own. However, if the patient or their family members raise concerns about the care you are providing, gaps in your charting could be difficult to defend. As far as legal proceedings are concerned, the general idea is that if you didn’t chart it, it didn’t happen.
Make sure you chart the work you do and follow organizational policies. This means completing all assessments and other tasks within the allotted time frames.
Late Entries
There are plenty of times when you need to make late entries. After all, you can’t chart everything in real time. Patient care comes first.
But you need to keep track of the work you do and properly back-time your entries based on when you performed the tasks. Forgetting to back-time your charting within policy can make it appear as if you are performing important care tasks late.
Be diligent about including the correct times and dates when charting the care you provide. This is especially important when you work the overnight shift and are charting things that took place around midnight. Something as simple as forgetting to change the date can throw off your charting.
Frequently Modifying Records
Most electronic health record (EHR) platforms allow you to modify records so that you can correct typos and other simple mistakes. The nursing board understands that these errors happen and allows for some modification of records. However, if you are frequently modifying records like vital signs and medication administration times, it can be a serious red flag.
Be diligent and chart things as accurately as possible the first time. Occasionally, making an update to a small detail is acceptable and expected.
If you need to, jot down paper notes as reminders for yourself so that you can chart accurately later. Make sure you follow HIPAA and other applicable patient privacy laws when taking notes.
Contradictory Documentation
Inconsistencies in a patient’s chart are one of the biggest red flags that can trigger a nursing board investigation. The greatest risk for contradictions occurs when a nurse hands off a patient at shift change.
For instance, perhaps the previous nurse charted a pressure injury on a patient’s coccyx during their shift. However, the oncoming nurse does not perform a complete head-to-toe assessment or review the previous documentation. Instead, they simply chart the patient’s skin as Within Normal Limits (WNL) and intact.
Those are the types of mistakes that can trigger a nursing board investigation. To make matters worse, the board may conduct a deeper review of your charting to look for similar oversights. Nurses with a pattern of lax or inaccurate charting could face harsher discipline.
A Lack of Nurses’ Notes
When in doubt, you should add a nurse’s note to document the care you provide and any discrepancies in charting. If a patient is off the unit for a CT scan, for instance, and it causes one of your assessments to be completed late, you would do the assessment as soon as the patient returns to the unit and add a nurse’s note explaining why the assessment was late.
Nurses’ notes are a tool to protect you and give you a chance to elaborate on activities that occur throughout the shift. Failing to use them could leave you susceptible to an investigation and the repercussions that come with it.
Nursing Documentation Red Flags You Might Have That Can Get You In Trouble
| Documentation Issue | Why It May Raise Concerns | Better Documentation Practice |
|---|---|---|
| Incomplete charting | Missing assessments or care documentation can create questions about whether required care was completed. | Document required assessments and care according to facility policies. |
| Late entries | Incorrect dates or times can make care appear delayed or create inconsistencies in the record. | Clearly identify late entries and accurately document when the care occurred. |
| Frequent record modifications | Repeated changes to important information may draw additional scrutiny. | Chart accurately the first time and follow EHR and facility procedures when corrections are necessary. |
| Contradictory documentation | Conflicting information between nurses or shifts can raise questions about the accuracy of the patient record. | Review prior documentation and perform required assessments before charting findings. |
| Missing nurses’ notes | Unexplained delays, unusual events, or discrepancies may leave important gaps in the record. | Use nurses’ notes when appropriate to provide relevant context about patient care. |
Contact a Nursing License Defense Attorney Before Responding to a Nursing Board Investigation
If you are facing an investigation into your nursing license, it’s vital to seek legal representation right away. S J Harris Law focuses on providing professional license defense services to clients throughout California. Contact us for a free 30-minute phone consultation now.
