Good Documentation Is a Nurse’s Best Defense

The medical record is the most important piece of evidence in a malpractice lawsuit, Wortham said, forming the basis for both allegations and defense. Because lawsuits can take years to emerge, nurses should not take a chance by relying on their memory of events. Instead, documentation should reflect a patient’s condition and every aspect of the nursing care delivered.

The most important role of nursing documentation is to ensure quality care, because effective communication between healthcare providers is critical to patient safety. The detailed notes nurses create are used to validate reimbursements from third-party payers, ensure compliance with government agencies and accrediting bodies, and protect against allegations of negligence or malpractice.

Although the principles of nursing documentation are not new, legal cases continue to be lost as a direct result of poor documentation. Nurses must have renewed commitment and vigilance to creating a record that will not only ensure patient safety but also provide a defense against allegations of negligence or malpractice.

Wortham suggested following these steps to ensure adequate documentation in a patient’s record:

• Describe the event objectively.
• Document your assessment.
• Chart the care provided, who was notified, and what their response was.
• Use a patient’s own words to describe what happened, if appropriate.
• Document any change to the plan of care
• Document your reassessments.

Particular care should be taken when making late entries and addenda to documentation. A late entry supplies information that was omitted from the original entry and should be written only if a nurse has total recall of the omitted information. An addendum provides information that was not available when the original entry was written, and it should provide a reason for the addition or clarification.

Maug addressed documentation of informed consent and in electronic medical records (EMRs). Informed consent is much more than simply reviewing the possible side effects of treatment or obtaining permission and a signature, she said. It is a process that allows patients to make a well-considered decision about their care. The informed consent process must include an assessment of a patient’s ability to understand relevant medical information, its implications, and the implications of treatment alternatives, and to make an independent, voluntary decision.

Nurses need to be aware that every piece of information that is entered—or not entered—into an EMR could become evidence in a lawsuit, Maug said. The record should include all pertinent information so that it will tell a reviewing attorney a patient’s story in its entirety. The quality of documentation can make the nurse appear competent or, alternatively, careless.