Related Experiment Videos
Charting accuracy of scheduled medications in the medication administration record
Abstract:
This study was designed by the pediatric clinical pharmacy service to evaluate the accuracy of the nursing Medication Administration Record (MAR). Medications returned to the pharmacy in the exchanged medication carts were compared to those charted in the computer-generated MAR for 10 working days. Fourteen percent of the doses studied were categorized as charting errors. Charting inconsistencies were summarized in a personalized memorandum distributed to the nursing staff on the pediatric unit. A subsequent evaluation revealed a 10% charting discrepancy rate. The nursing memo did not effect a statistically significant change in the error rates between the two phases of the study. Inaccurate charting poses problems for therapeutic decision making and for methods of reimbursement that use the MAR. This problem should be assessed in individual institutions. Corrective measures should be implemented and evaluated.
Related Concept Videos
Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security:
Flow Sheet
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Methods of Documentation IV: Focus Charting
It typically involves three columns for recording information:
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Methods of Documentation VI: Case Management Model
For example, a patient with a chronic illness...
Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.