One of the most vital components of good nursing care is proper documentation. This practice of thoroughly and completely recording each interaction with your patients is made even more important when you consider the possibility of legal action against you.
“The first thing a patient considering a lawsuit will do is request the medical records.”
Knowing that patient 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 a judge or jury might both hear and see them.
“Anything you write could be read in court.”
Strive to chart in the most comprehensive way possible. Time restraints are the biggest obstacle for you!
It can take years for a lawsuit to culminate; it’s unlikely you’ll remember everything clearly if you get sued.
Your charts and documents are the key to knowing what you did and why you did it, so be sure you chart information to recall the specifics of the case.
The longer you wait to complete your charting, the more it may look you are trying to falsify the actual occurrence after the fact.
The nursing adage “if it is not documented, it is not done” should always be applied to your work. Also consider that, unless you documented an action or treatment, legally speaking it never occurred.
Of course, not every mistake rises to the level of a lawsuit, and accurate charting is important for the proper care and treatment of patients. But the need for understandable and comprehensive charting becomes far more important if a case goes to court.
A fundamental aspect for healthcare providers named as defendants in a lawsuit is the ability to recall, sometimes years after caring for a patient.
The more information you include in your charts, the easier it will be for you avoid being unfairly accused.
P.S. Help yourself and your nursing colleagues here.
