NCM 119A Nursing Leadership and Management

AY 2022-2023
Chapter V
RECORDS MANAGEMENT

Records management is “responsible for the efficient and systematic control of the
creation, receipt, maintenance, use and disposition of records, including processes
for capturing and maintaining evidence of and information about business activities
and transactions in the form of records”.

Records management is the process of identifying and protecting evidence, which comes
in the form of records.

What is the concept? What does it mean to you?

Information is “data, ideas, thoughts, or memories
irrespective of medium.” Information sources are
considered “non-records”: they are useful but do not
provide evidence. Examples include journals,
newspapers, publications, or reference sources not
created by the UN.
Documents are any “recorded information or objects
that can be treated as individual units.” Examples
include works in progress such as draft communications
or “to do” lists, and transitory records such as emails
confirming a meeting or acknowledging receipt of a
document.
Records are “information created, received, and
maintained as evidence and information by an
organization or person, in pursuance of legal obligations
or in the transaction of business.” Examples include final
reports, emails confirming an action or decision,
spreadsheets showing budget decisions, photographs or
maps of field missions, which need to be kept as
evidence.
Archives are those records that have been selected for
permanent preservation because of their
administrative, informational, legal and historical value
as evidence of official business of the UN. Archives are
very small but important subset of the UN’s official
records.
If the item in question provides information only and
does not provide evidence of an activity, decision, or
transaction related to your work at the UN, you should
destroy the information when you no longer need it.
If a document is superseded by other documents, such
as a draft report that is replaced by a newer version,
and the first draft is not needed as evidence,
or if the document contains information that you need
for only a short time – like a confirmation of the location
of a meeting – you should destroy the document when
you no longer need it.
If you created or received the document in the course of
your work and it provides evidence of an activity,
decision, or transaction, you need to keep it as
evidence, according to established UN retention
schedules. That document becomes a record and must
be stored safely so it remains accessible.
UN ARMS is responsible for helping you manage your
records in order to protect valuable evidence of UN
operations. UN ARMS also ensures records with archival
value are preserved and made available.
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A. Data Privacy Protocols in Data Safekeeping and Release Records

1. Sentinel Events - is a patient safety event that results in death, permanent harm,
or severe temporary harm. Sentinel events are debilitating to both patients and
health care providers involved in the event.

Serious reportable events can be classified into the following categories:

1. Surgical
2. Device/product
3. Care management
4. Environmental
5. Patient protection
6. Radiologic event
7. Criminal events
Hospitals vary in their definitions, investigations, and reporting of the sentinel
events. Examples of sentinel events from the Joint Commission include the following:
 Suicide during treatment or within 72 hours of discharge
 Unanticipated death during care of an infant
 Abduction while receiving care
 Discharge of an infant to the wrong family
 Hemolytic transfusion reaction due to blood transfusion with major blood
group incompatibilities
 Surgery on the wrong individual or wrong body part
 Retained foreign body after surgery
 Severe neonatal jaundice (bilirubin >30 mg/dl)
 Prolonged fluoroscopy with very high or inappropriate dose or to the wrong
site
 Fire during direct patient care caused by hospital equipment
 Intrapartum maternal death
 Unanticipated severe maternal morbidity resulting in permanent or severe
temporary harm
 Rape
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 Falls
 Delay in treatment
 Medication error
 Criminal event
The hospital must review all sentinel events. Sentinel events occur in every
healthcare setting. The great majority occur in a medical/surgical hospital setting,
followed by psychiatric hospitals (including psychiatric units and clinics) and
emergency departments. More than three-fourths of them are voluntarily reported
to the agency. The most common sentinel events are wrong-site surgery, foreign
body retention, and falls. They are followed by suicide, delay in treatment, and
medication errors. The risk of suicide is the highest immediately following
hospitalization, during the inpatient stay, or immediately post-discharge. Fortunately,
infant discharge to a wrong family has been reduced to zero. Hemolytic transfusion
reactions due to major blood group incompatibilities are still reported with an
incidence of 7-9 per year.
An appropriate response to a sentinel event may include the following:
 Stabilize the patient
 Disclose the event to the patient and family
 Provide support for the family and staff involved
 Notification to the hospital leadership
 Immediate investigation
 Comprehensive systematic review
 Root cause analysis (RCA) for identifying the causal and contributory factors
 Strong corrective actions to eliminate the root cause and prevent similar
future events
 Establish a timeline for the implementation of corrective actions
 System improvement

Sentinel Event Policy

All healthcare organizations should have a policy for responding to a sentinel event.
In 1996, the Joint Commission instituted a formal sentinel event policy. It partners
with the hospitals that have experienced a sentinel event in the investigation,
analysis, and development of corrective action plans. The policy has the following
goals:
 Improve patient care and prevent such safety events in the future
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 Analyze the root causes that contributed to the sentinel event (culture, latent
and active failures), and develop strong, actionable plans
 Enhance the general awareness and disseminate the learnings about patient
sentinel events, root factors, and mitigation strategies
 Maintain trust of the public, staff, and hospitals that patient safety is a
topmost priority
Sentinel Event Database
The Joint Commission collects and analyzes the data from the sentinel events
reviewed and reported by the organizations. The de-identified data helps in general
awareness and dissemination of error prevention strategies to all hospitals. The Joint
Commission’s website provides resources on sentinel events, statistics, webinars,
and quick safety tips.
Reporting a Sentinel Event to the Joint Commission
Reporting a sentinel event to the Joint Commission is voluntary. The advantages of
reporting the sentinel event include:
 The lessons learned from the sentinel event increase the awareness of the
potential sentinel events, root causes, and strategies for prevention. Other
hospitals and organizations can learn from the Joint Commission’s sentinel
event database.
 Self-reporting allows consultation with Joint Commission staff for the
systematic review and root cause analysis of the sentinel event and
developing an action plan.
 It reinforces the hospital’s message to the public and staff regarding its
culture of safety.

The National Patient Safety Foundation developed guidelines to standardize the

RCA process and direct organizations for improvement efforts. They emphasized that
action steps are needed after the analysis is completed and renamed as root cause
analysis and action (RCA2). After the cause is identified, solutions to the problem or
error should be recognized and implemented. RCA2 differs from other patient safety
tools like the failure mode effect analysis (FMEA) and the situation background
assessment recommendation (SBAR). FMEA is a systematic, proactive method for
identifying potential risks and assess their impact before harm has occurred. SBAR is
a framework for communication between team members about a patient's condition.
RCA2 must be thorough and credible. The sequential steps in an RCA2 are:
 Identifying multidisciplinary team members for RCA2
 Gathering all the relevant information
 Organizing the collected information
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 Identifying the root cause
 Developing a strong action plan
 Reporting
Every healthcare organization should have a stepwise crisis management plan for
the effective and respectful management of a sentinel event. The proper disclosure
of adverse events to patients with the involvement of risk management is required.
Several states mandate full disclosure of errors. The goal of RCA2 is to identify and
mitigate system errors and prevent future occurrences. A collaborative
interprofessional team approach is needed for a successful and timely
implementation. Strong actions help in standardizing and simplifying the workflow
process. The process aims at continuous improvement and promotion of patient and
family-centered care. It is a step towards enhancing the organizational culture of
safety and promoting a just, non-punitive, and fair culture.
Effective second victim programs help in providing support and education to the
staff. Patient safety organizations can provide guidance and actionable
recommendations to improve patient safety in the hospital environment. They
provide a toolkit for optimal communication and resolution. They can also help to
disseminate the lessons learned from the sentinel events.

2. Anecdotal Record
- An anecdotal record is an observation that is written like a short story.
They are descriptions of incidents or events that are important to the
person observing. Anecdotal records are short, objective and as
accurate as possible.
- A record of some significant item of conduct, a record of an episode
of the life of students, a word picture of the student in action, a word
snapshot at the moment of the incident, any narration of events in
which maybe significant about his personality.
Characteristics of anecdotal records:
 Anecdotal records must possess certain characteristics as:
o They should contain a factual description of what happened, when it
happened, and under what circumstances the behavior occurred.
o The interpretations and recommended action should be noted
separately from the description
o Each anecdotal record should contain a record of a single incident
o The incident recorded should be that is considered to be significant to
the
o Accurate students’ growth and development of example
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o Simple reports of behavior
o Result of direct observation
o Accurate and specific
o Gives context of child’s behavior
o Record typical or unusual behavior
Uses of Anecdotal Records:
 Records unusual events, such as accidents.
 Records children’s behavior, skills and interest in planning purposes
 Record how an individual is progressing in a specific area of development
 It provides a means of communication between the members of health care
team and facilitates coordinated planning and continuity of care. It acts as a
medium of data exchange between the health care team.
 Clear, complete, accurate, and factual documentation provides a reliable,
permanent record of patient care.
Advantages of Anecdotal Record:
 Supplements and validates of other structured instruments
 Provision of insight into total behavioral incident
 Needs no special training
 No use of formative feedback
 Economical and easy to develop
 Open ended and can catch unexpected events
 Can select behaviors or events of interest and ignore others, or can sample a
wide range of behaviors’ (different times, environments and people).
Disadvantages of Anecdotal Records:
 If carelessly recorded, the purpose will not be recorded
 Only records events of interest to the person doing the observing.
 Quality of the record depends on the memory of the person doing the
observing
 Incident can be taken out of context.
 Subjectivity
 Lack of standardization
 Difficulty in scoring
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 Time consuming
 May miss out on recording specific types of behavior
 Limited application
3. Incident Report:
- A patient incident report, according to Berxi, is “an electronic or paper
document that provides a detailed, written account of the chain of
events leading up to and following an unforeseen circumstance in a
healthcare setting.”
- Reports are typically completed by nurses or other licensed personnel.
They should then be filed by the healthcare professional who
witnessed the incident or by the first staff member who was notified
about it.
- Patient incident reports should be completed no more than 24 to 48
hours after the incident occurred. You may even want to file the
report by the end of your shift to ensure you remember all the
incident’s important details.

The Purpose of Patient Incident Reports

Patient incident reports communicate information to facility administrators. The
information contained in the reports sheds light on measures that need to be taken
to provide effective patient care as well as keep your facility running smoothly.
These reports help administrators with:

 Risk management. Knowing that an incident has occurred can push

administrators to correct factors that contributed to the incident. This
reduces the risk of similar incidents in the future.
 Quality control. Medical facilities want to provide the best care and customer
service possible. Reviewing incident reports reveals areas that could be
improved.
 Training. Using resolved patient incident reports to train new staff helps
prepare them for real situations that could occur in the facility. Similarly,
current staff can review old reports to learn from their own or others’
mistakes and keep more incidents from occurring.
 Legal evidence. Should a patient take legal action following their incident, a
thorough incident report is the most important part of any defense. Thus, all
reports should be timely, complete and accurate.
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TYPES OF PATIENT INCIDENT
Harmful Incident
A harmful incident results in injury or illness to a patient or another
person. For example, a patient could fall out of bed and break their arm or
scratch a nurse as the takes their temperature
Near Miss
A near miss is when there was potential harm to a patient or another
person was almost harmed but the situation was corrected before it occurred.
For instance, a patient might get caught trying to leave the facility
prematurely or trip but a nurse catches them before they fall.
No-Harm Incident
A no-harm incident means that something happened to a
patient or another person but no discernable injury or illness resulted. For
example, a patient could be given a blood transfusion meant for another
patient but no harm was done because the blood was compatible.

Types of patient incidents that may occur include:

 Patient complaints (e.g. problems with care or care provider)

 Unexpected events related to treatment (e.g. adverse reaction to medication,
equipment malfunction)
 Bodily harm (e.g. injury to patient, staff, contractor or visitor)
 Patient-related events (e.g. treatment refusal, leaving against doctor’s orders)

Even if an incident seems minor or didn’t result in any harm, it is still

important to document it. Whether a patient has an allergic reaction to a medication
or a visitor trips over an electrical cord, these incidents provide insight into how your
facility can provide a better, safer environment.

What to Include in a Patient Incident Report?

A patient incident report should include the basic information about the
incident: the who, what, where, when and how. You should also add
recommendations on how to address the problem to reduce the risk of future
incidents.
Every facility has different needs, but your incident report form could include:

 Date, time and location of the incident

 Name and address of the facility where the incident occurred
 Names of the patient and any other affected individuals
 Names and roles of witnesses
 Incident type and details, written in a chronological format
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 Details and total cost of injury and/or damage
 Name of doctor who was notified
 Suggestions for corrective action

Most importantly, provide as much detail as possible in your patient incident reports.
The more information you provide about what caused the incident, the better your
chance of stopping similar incidents.

Tips for Efficient Reporting

1. Be Objective
In order to record the most accurate account of the incident, maintain an
objective tone. Do not include assumptions or assign blame; just write down the
facts. Where possible, include direct quotes from the patient and/or other involved
parties.
2. Write Clearly
The higher your quality of writing, the more valuable your patient incident
report will be. For example, using clear, concise language will make the investigation
process faster and easier. In addition, use proper grammar, spelling and punctuation.
Grammar mistakes may change the meaning of details within the report, which may
make investigating the incident more difficult.
3. Use Case Management System
Managing patient incident investigations can be stressful, especially if your
facility serves hundreds of patients at any given time. Using case management
software, though, streamlines the process so you can improve your facility’s quality
of service.
Choose a platform that is web-enabled for quick reporting. You’ll never miss
important details of a patient incident because you can file your report right at the
scene.

4. Kardex
- A medical-patient information system which uses forms preprinted on
durable card stock; loosely, any similar system for paper-based
record-keeping.
- originally, the proprietary name for a filing system for nursing records
and orders that was held centrally on the ward and contained all the
nursing details and observations of patients that had been acquired
during their stay in hospital. Although this system is no longer used
for nursing records, since care plans are now held at the patient's
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bedside rather than centrally, the term ‘kardex’ continues to be used
generically, for certain centrally held patient record systems.
- A Kardex is a medical information system used by nursing staff as a
way to communicate important information on their patients. It is a
quick summary of individual patient needs that is updated at every
shift change.
- is a desktop file system that gives a brief overview of each patient
and is updated every shift. It is like having a cheat sheet for nurses to
reference that is separate from the patient chart. It is usually kept in a
central location, such as the nursing station, for quick access.
- Kardex is actually the brand name and trademark for the original
cardstock system. The original system was a desktop file (similar to a
large rolodex) that had slots for multiple pages. Thick cardstock pages
were inserted into the slots, one for each patient. The pages were
written on in pencil and was updated every shift.
What is included in a Kardex?
 patient name
 age
 status regarding whether or not to resuscitate the patient (Do Not
Resuscitate status)
 marital status
 religious affiliation
 allergies
 medical diagnoses
 emergency contact numbers
 permitted activities
 functional limitations.
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Example of Kardex

5. Patient’s Chart/Records
- A medical chart is a complete record of a patient’s key clinical data
and medical history, such as demographics, vital signs, diagnoses,
medications, treatment plans, progress notes, problems,
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immunization dates, allergies, radiology images, and laboratory and
test results.

A medical chart is comprised of medical notes made by a physician, nurse, lab

technician or any other member of a patient’s healthcare team. Accurate and
complete medical charts ensure systematic documentation of a patient’s medical
history, diagnosis, treatment and care.

What kind of information comprises a medical chart?

Ideally, medical charts contain records of every medically relevant event that
has happened to a patient since birth. Events include diseases, major and minor
illnesses, and growth landmarks. A medical chart should give any clinician an
understanding of everything that has occurred previously to the patient. This is
crucial to help healthcare providers diagnose current disease states.

A medical chart includes:

 Surgical history (e.g., operation dates, operation reports, operation narratives)

 Obstetric history: (e.g., pregnancies, any complications, pregnancy outcomes)
 Medications and medical allergies
 Family History (e.g., immediate family member health status, cause of death,
common family diseases)
 Social History (e.g., community support, close relationships, past and current
occupation)
 Habits (e.g., smoking, alcohol consumption, exercise, diet, sexual history)
 Immunization Records (e.g., vaccinations, immunoglobulin test)
 Developmental History (e.g., growth chart, motor development,
cognitive/intellectual development, social-emotional development, language
development)
 Demographics (e.g., race, age, religion, occupation, contact information)
 Medical encounters (e.g., hospital admissions, specialist consultations,
routine checkups)
During a medical encounter, medical charts will include any and all summations
relevant to the patient’s care, including:

 Chief complaint
 History of the present illness
 Physical examination (e.g., vital signs, muscle power, organ system
examinations)
 Assessment and plan (e.g., diagnosis, treatment).
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 Orders and prescriptions
 Progress notes
 Test results (e.g., imaging results, pathology results, specialized testing)

How an Electronic Health Record Can Help:

An electronic health record, or EHR, is set up to ensure that medical charts
are complete and accurate. Think of it as a digital version of a patient’s paper
medical chart. With good EHR software and EHR systems, health care providers will
be alerted to any missing, incomplete, or possibly inaccurate medical charts.

An EHR is a real-time record that makes health information available instantly

and securely to authorized users. EHRs are built to share medical notes with other
health care providers and organizations – such as laboratories, specialists, medical
imaging facilities, pharmacies, emergency facilities, and school and workplace clinics
– so they contain information from all involved in a patient’s care. This has the
potential to automate and streamline health provider workflow.

The EHR also has the ability to support other care-related activities directly or
indirectly through various interfaces, including evidence-based decision support,
quality management, and outcomes reporting. An EHR also guarantees a patient’s
medical chart is never lost and stored in one easy to access location.

Compared to paper records, the use of EHRs can improve patient care tremendously.
They can:

 Reduce the incidence of medical error by improving the accuracy and clarity
of medical records and coordination of diagnosis and treatment among
health providers
 Make the health information instantly accessible, reducing duplication of
tests, reducing delays in treatment, and patients well informed to take better
decisions.
 Allow patients to log on to her own record and see lifetime health trends to
be better informed about their health

Guidance to help keep charting at its best:

1. Failing to record pertinent health or drug information

It comes as no surprise that maintaining a correct and complete medical

history is vital for providing proper treatment. However, the importance of this point
is further underscored by the fact that failure to record key details such as allergies,
diseases, and current medications can leave nurses personally liable for negligent
patient care.
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In one example, a nurse neglected to note a patient’s penicillin allergy during
the initial intake process. Without a proper record or indication of the allergy, a
hospital intern unwittingly administered what turned out to be a debilitating and
ultimately lethal dose of the drug as part of what was by all accounts a standard
procedure. It was this one innocent charting mistake that had devastating
consequences—the patient immediately went into anaphylactic shock and suffered
irreversible brain damage. At the trial, the court found the admission nurse guilty of
negligence in a case of avoidable patient death.

Asking the right questions is only half the battle. In the end, what matters is
that all relevant information ends up recorded in enough detail for subsequent
hospital personnel to be able to pick up and rely on throughout the entire course of
treatment. Take extra initiative to notify other staff members on rotation, make sure
the information is on their identification bracelet, and comply with hospital policies
in place surrounding EHR procedures. It only takes one charting mistake to put lives
and licenses at risk, so everyone needs to be on the same page.

2. Failing to document prior treatment events

It is essential to record every detail of a patient’s treatment, especially when

treating multiple patients and across shifts. Individual patient developments can
seem inconsequential in isolation, but even small errors can compound on
themselves the longer an oversight persists.

Take a patient coming out of surgery, for example. The day nurse observes
heavy drainage from a surgical wound and changes the patient’s dressing. However,
the day nurse forgets to record both the dressing change and the heavy drainage
before leaving at the end of his shift. Later, the evening nurse also notices heavy
drainage from the wound and checks the previous nurse’s notes for any indication of
a prior dressing change.

Because the day nurse did not leave any notes indicating the patient’s course
of recovery, however, the evening nurse considers the amount of drainage normal
for a period of several hours. She too changes the patients dressing but then also
omits the bandage change in the chart.

This pattern continues throughout the next day, each nurse leaving the next
no indication of concern for the patient’s wound. Is the condition getting more
serious? Is the patient’s life in jeopardy? No one knows because no one realizes that
the patient’s wound is seeping more than it should.

The most common excuse for omissions or holes in charting information is a

lack of time to record everything thoroughly. And while it’s true that healthcare work
is often highly demanding on time, that doesn’t mean nurses have to compromise on
quality to get everything done—there have been plenty of helpful tools and
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strategies developed by people facing these exact same problems over the years.
One efficient practice involves flow sheets that can be included in the patient EHR at
the end of a shift. Leverage hospital standard flow sheets whenever possible, and ask
where to find them in the HER system if you can’t locate them easily.

3. Failing to record those medications have been administered

Lifesaving drugs can all too quickly become life-threatening when

administered improperly—either through overdose or adverse interactions. As such,
it is central to record every medication given to the patient over the entire course of
treatment—including the dose, route, and time of each administration.

A day nurse once gave a patient heparin by intravenous push just before she
went off duty. An hour later, the evening nurse saw that an order had been placed
for heparin—but no indication that the medication had already been given. The
evening nurse then proceeded administer the full dose once again, causing the
patient to hemorrhage to the point of hypovolemic shock. Fortunately, the patient
survived the ordeal, but he went on to successfully sue the hospital for malpractice
in administering an entirely avoidable overdose.

Both nurses made mistakes in this situation. The day nurse should have
recorded that the patient had received his medication, but the evening nurse also
should have been suspicious of the heparin order with no indication that the dose
had been administered. In this scenario the nurse could have protected both the
patient and the hospital by taking a few simple steps to mitigate risk to the patient.
Asking the patient if they have received their medication, confirming with the
hospital pharmacy about whether or not the medication had been furnished, or even
reaching out the previous nurse directly all could have prevented the more perilous
error and the lawsuit that followed it.

As a rule of thumb, nurses should avoid making assumptions when they

notice gaps or missing information in a patient’s treatment documentation.
Healthcare professionals have exceedingly demanding schedules, but it’s always
better to take the time and double-check the details than to make assumptions and
be wrong.

4. Recording on the wrong patient’s chart

Given the sheer volume of patients the average hospital commonly treats at a
time, there are any number of ways one patient might confuse with another—an
honest mistake with potentially dire consequences. As such, nurses really can’t be
too careful in validating all the individual details that might cause two patients to get
mixed up: similar names, similar conditions, physical proximity, or even having the
same attending physicians.

Consider an instance where a nurse had two unrelated patients who happened
to share a last name. Mrs. B. Moyer and Mrs. C. Moyer were on the same unit. Mrs.
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B. Moyer was being treated for severe hypertension; Mrs. C. Moyer, for acute
thrombophlebitis. Mrs. C. Moyer’s doctor ordered 4,000 units of heparin for her.

The nurse mistakenly transcribed the heparin order onto Mrs. B. Moyer’s chart
and administered the heparin to the wrong patient, and as a result, Mrs. B. Moyer
started bleeding. This, of course, would expose both the hospital and the nurse to
malpractice liability far more costly than the time required to double-check the
name on the sheet.

When there are two or more patients with the same name, be sure a different
nurse is assigned to each patient; develop a system of flagging the patients’ names
and medication records. And always double-check wristbands before giving
medications.

5. Failing to document discontinuation of a medication

If a patient is scheduled to be taken off a medication after a given period of time

once therapeutic effects have been achieved (or before adverse ones come about), it
is essential to document this detail so that doctors, nurses, and patients are all
aware.

For example, a doctor once suspected that his patient had developed an ulcer
after habitually taking high doses of aspirin for arthritis. The doctor summarily
ordered discontinuation of the drug to avoid further aggravation of the ulcer, but the
attending nurse at the time neglected to record this detail into the patient’s chart. As
a result, this detail never made it back to the other nurses on duty, who continued
administering the patient aspirin and exacerbating the bleed—as the doctor had
warned. Eventually the patient’s ulcer deteriorated to the point of requiring a partial
gastrectomy, after which she successfully sued the hospital for the nurses’
negligence. Adopting the simple practice of cross-checking doctors’ orders and
medication sheets can prevent mistakes likes these.

6. Failing to record drug reactions or changes in the patient’s condition

Monitoring a patient’s response to treatment isn’t enough. Once a nurse

recognizes an adverse drug reaction or a worsening of the patient’s condition, it is
their responsibility to proactively intervene (or notify someone better equipped to
do so) and then document the occurrence to prevent it from happening again.

A patient once complained of nausea, dizziness, abdominal pain, and itchy

skin shortly after receiving his first 100-mg dose of nitrofurantoin macrocrystals
(Macrodantin). Having administered the same drug to many patients with no
adverse reactions over the course of their career, the attending nurse did not take
concern to any of the symptoms the patient was reporting. By evening, after two
more doses of the same medication, the patient was suffering from vomiting, high
fever, urticaria, and early symptoms of shock. The patient later sued his nurse for
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negligence.

The fact that most patients don’t have adverse reactions to a given drug
shouldn’t dull nurses’ vigilance in administering it. Every drug has side effects, and
contraindications can vary drastically from one person to the next based on their
entirely unique internal conditions. So observe patients closely, always consider the
possibility of adverse reactions when a patient reports new symptoms, and follow up
promptly and proactively.

7. Transcribing orders improperly or transcribing improper orders

Patients’ nurses are responsible for familiarizing themselves with a patient’s

medications, procedures, and activities as well as documenting ongoing
developments in treatment for the reference of others. A great responsibility indeed,
and with it comes liability. If transcribing orders on the wrong chart or transcribing
the wrong dose, nurses can be held liable for any resulting injury. Nurses can also be
held liable if they transcribe or carry out an order as it’s written if they know or
suspect the order is wrong. As these instances can entail serious legal consequences,
nurses must take it upon themselves to understand the details of their patient’s
treatment well enough to recognize when something isn’t right.

Sometimes, a nurse can carry responsibility for blindly transcribing a doctor’s

mistakes. For example, one doctor intended to order 0.5ml of atropine for a patient.
However, the doctor had forgotten to write the decimal point on the order and the
transcribing nurse proceeded to request a 5ml dose, although she had been
suspicious that there may have been a mistake. In this case, the nurse can potentially
be held liable for negligence in deciding that the doctor probably knew best and
failing to consult her own best judgment.

Medication errors like this are among the most common in the entire
healthcare industry. So, if at all suspicious that a mistake or miscommunication has
occurred somewhere in patient’s treatment or prescribing information that could
put them at risk, absolutely do not hesitate to reach out and double-check.

6. 201 File

- An employee 201 file, usually containing records pertaining to the

employee's personal information, employment contract, duties, salary,
performance and employment history, among others, is established and
maintained by an employer for specific purposes relating to the employee's
employment.
- Interestingly, the term “201 file” originated from the Army. Form 201 in the
US Army is a set of documents containing a person's comprehensive profile,
NCM 119A Nursing Leadership and Management
AY 2022-2023
including all past and current information necessary to know almost
everything about him

Why is it called 201 file?

Why is the 201 File of Employees called the 201 File? It’s a term borrowed
from the military, specifically the US Army. The US Army’s folder for personnel
record is called the DA Form 201, or 201 File. We borrow a lot of terms from the
military since they are considered in history as the 1st formal organization.

What should be included in 201 file?

Every company must have a 201 File for each employee that keeps documentation
on an employee’s history with an organization.

 Full name.
 Date of birth.
 Address.
 Contact information.
 SSS number.
 BIR number.
 Tax identification number.
 PhilHealth number.

https://archives.un.org/content/understanding-records-management
https://www.ncbi.nlm.nih.gov/books/NBK564388/
https://study.com/academy/lesson/what-is-kardex-definition-use-in-nursing.html
https://www.practicefusion.com/medical-charts/