One of the most vital components of good nursing care is proper documentation. As a Professional Legal Nurse Consultant (PLNC) reviewing nursing records, your job is to thoroughly check all documentation. You know as a nurse that this practice of completely recording each interaction with your patients is made even more important when you consider the possibility of legal action against you.
Nurses need to know this: The first thing a patient considering a lawsuit will do is request their medical records, including any and all charts and documents you created.
Patients will, of course, be searching for errors. These records are of great consequence in the legal process.
Knowing that patients will get the medical records should be motivation enough to make the records thorough and detailed. Remember, anything you write could be read in court. When you make notes, think in the back of your mind that a judge or jury might both hear and see them.
Here’s your Nursing Checklist to an Effective Paper or Electronic Trail:
- Don’t leave anything blank that should’ve been completed
- Complete all required forms
- Chart thoroughly
- Log out so no one can chart for you
We all learned in nursing school “if it’s not documented, it’s not done”. Professional Legal Nurse Consultants know this. Jurors are drilled with this adage also. Make sure YOU follow this wisdom.
P.S. Comments below about what documentation steps you always follow.
