"Avoiding malpractice through proper documentation".
By the time a lawsuit is filed, chances are the nurses will not remember the particular patient involved, especially if they only cared for the patient for one or two shifts. Even if the nurses do remember the patient, it is their documentation that will be reviewed, presented and relied on, not their memory.
All nurses have been taught, "If it's not written, it's not done!" But, what exactly does that mean? Whether you are a student nurse or have been in nursing for thirty years, this question may be difficult to answer.
Over the years, documentation has changed a great deal. But, the rationale behind why documentation is important remains the same. Whether you are documenting with a narrative style, using flow sheets or charting by exception, the purpose of documentation is to memorialize what occurred while you took care of your patient and to capture relevant information about the patient's condition and medical history. The more accurately your documentation depicts what actually happened during the time you took care of your patient, the more likely you are to avoid becoming involved in litigation for malpractice.
Regardless of the type or style of charting a nurse uses, it is important for documentation to be legible, logical, and complete. Not only to prove what occurred, but to also show what did not occur. For example, if a patient is admitted to a facility with both arms in tact, and claims to have left the facility with a broken arm, the first thing the patient's attorneys and their experts are going to do is review the medical records. They will try to determine from the records when and how this patient's arm could have been broken.
If the nurses have documented properly in this example, their charting should be able to establish that the patient's arm was either already broken or could not have been broken while the patient was under their care. The most difficult thing about this is the nurses involved would not likely be aware at the time they took care of this patient that two years later, he or she would be claiming to have broken an arm while under their care.
With all of the forms, flow sheets and check lists nurses are expected to use, it is easy to omit important information. These flow sheets and other forms were created to help nurses to be more complete in their documentation. By listing all of the general systems a nurse will assess, the goal was to reduce the amount of information that was being omitted. However, what has happened is most nurses have stopped thinking about the complete physical assessment on their own and have learned to rely on the forms as a complete guideline to their documentation.
The danger with relying on forms to completely document a patient's condition is that invariably, there will be information that is necessary and unique to the patient that was not thought of by the person creating the flow sheet or check list.
When important facts and findings do not fit the form, rather than conforming to the form, the form needs to be conformed to fit the facts. This is an area where nurses literally need to be thinking outside the box. A good example that all nurses can relate to is the question commonly seen on admission forms and other documents, "Do you smoke, yes or no?"
Fortunately, today, many people have chosen not to smoke. When someone is asked whether or not they smoke, if they are not currently smoking, they will obviously answer, "no" to this question. However, nurses need to remember why this question is being asked. If the patient quit smoking a month ago after smoking three packs a day for thirty years, answering "no" will not be sufficient. While technically this answer would be correct, it would not provide the reviewer with the whole picture. The nurse in this case should also ask, "Have you ever smoked, if so, for how long, how often," and so on. In fact, not including this information could be detrimental to a case when the attorneys are reviewing the records in a lawsuit.
Whether you are a nurse who is working in a hospital, a doctor's office, or in home health, documentation is equally important for avoiding malpractice and litigation. Your charting should be legible, accurate and complete. If you would like to learn more about how you can avoid malpractice and litigation through proper documentation, or sign up for upcoming seminars on avoiding malpractice, you may contact Tracy L. Singh, RN, JD directly via email at firstname.lastname@example.org or by calling (702) 444-5520.
Tracy L. Singh, RN, JD
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|Title Annotation:||75th Anniversary Celebration|
|Author:||Singh, Tracy L.|
|Date:||Nov 1, 2006|
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