A lot has happened over the past two years which permanently changed nursing and legal nurse consulting practice. The way you, as a certified Professional Legal Nurse Consultant (PLNC), review medical records will never be the same as pre-pandemic. You need to know what the legal landscape is now and going forward to make the necessary adjustments.
Let’s look at selected nursing challenges that the Covid pandemic has brought. In order to be an effective PLNC, you need to be able to size up the current documentation situation. Pre-pandemic, documentation was, on average, ample. Since the coronavirus outbreak, you’ll find charting has suffered.
Documentation Has Suffered
In your medical record review, your focus is almost entirely on the patient’s history and treatment course. You’d expect to find what you’re looking for in the Medication Administration Record, the Nurses’ Notes, Healthcare Providers’ Orders, Progress Notes, and any number of sections. Absent those entries, the assumption would be that it wasn’t done.
After all, that’s what nurses are taught in nursing school. We’re told the old adage “if it’s not documented, it’s not done”. That is not necessarily true anymore. Covid has taught us that. With nurses and other healthcare workers completely overwhelmed, guess what went by the wayside? DOCUMENTATION.
Without the benefit of documentation, the challenge becomes how do we figure out what was, and was not, done for the patient? This is where your Professional Legal Nurse Consultant skills come into play. You need to make a list of what documentation should have been present but wasn’t. Furthermore, you need to make a “Missing Documents” list specifically enumerating the documents that are not there but should’ve been completed.
Nurses Not Fully Prepared For Critical Care Practice
You’ll see in the patients’ charts nurses are likely not documenting in the manner you’d expect if they aren’t used to working in that specialty. For example, a pediatric nurse is likely not used to working on an Adult Covid Unit. This is especially problematic as the medication dosing for children versus adults can be significantly different. A pediatric nurse administering adult meds might not catch a medication error. You, as the PLNC, need to be on the lookout for this.
Not just with medications, but nurses who are floating to other specialty areas might not be used to providing clinical care in accordance with those standards of care. It’s up to you to research the standard of nursing care. Whether you’re consulting on legal cases for the plaintiff or defendant, you’ll need to provide some degree of research on nursing standards of care. Ultimately, you’ll have to decide if you think there was a breach of standard of care or if the facts support the standard of care.
Less Time Performing Nursing Assessments
When a nurse cannot do an appropriate initial assessment of the patient, it’s a slippery slope. For example, if the nurse failed to appropriately assess the condition of the patient at hospital admission, and later there’s documentation of decubitus, the assumption will be the patient’s condition deteriorated during hospitalization. This could mean liability for the hospital and the nurses. If the patient was accurately assessed at admission and the wound was noted, this could reduce the liability exposure.
In your legal nurse consulting merit review, carefully read all nursing assessments. Are they thorough? The answer might be “yes”, but you need to decide what should’ve been in them. If your answer is “no”, be prepared to explain why.
Crises Occur Online and Offline
Just because you didn’t see anything noteworthy in the medical records during your legal nurse consultant review doesn’t mean there isn’t a problem. If you’re reviewing the medical records in support of the nurse, see if you have access to Incident Reports. Still yet, see if you are allowed to read employee files, but these are usually protected documents.
If you’re reviewing records on behalf of the hospital, you might ask the attorney for their notes of the meeting or risk management’s notes. These can provide even more info that can help paint the full picture.
You need to know the legal landscape has forever changed when it comes to legal nurse consultant medical record reviews. What you might’ve come to expect from patient’s hospital or nursing course is not necessarily the norm anymore. Stay current by reading articles, blogs, and other scholarly material on how nursing practice has evolved.
Your Professional Legal Nurse Consultant skills are invaluable. Be proud. Be smart. Be sure to stay ahead of the pandemic, or endemic, curve.
P.S. Get your FREE Guide here so you can stay up-to-date on legal nurse consulting.
