In your Professional Legal Nurse Consultant (PLNC) practice, your main concern is with the medical record. Whether you’re reviewing a paper document or electronic health record, your approach will be the same.
Let’s look at charting from the perspective of a nurse. Whether you’re reviewing the documentation on behalf of the plaintiff or defendant, think about how the nurse goes about documenting nursing care. After all, if the nurses’ notes are at the center of a potential lawsuit, you’ll need to understand and interpret what was in the nurse’s mind at the time the event occurred.
Attorneys Want Your Nursing and Professional Legal Nurse Consultant Opinion
As a nurse, and a Professional Legal Nurse Consultant, the attorney is relying on your nursing opinion. What you say matters. So, let’s go into the mind of a nurse…
Here’s what a nurse should’ve been taught:
One of the most vital components of good nursing care is proper documentation. This practice of thoroughly and completely recording each interaction with patients is made even more important when you consider the possibility of legal action against you, the nurse providing care.
- The first thing a patient considering a lawsuit will do is request their medical records. This includes any and all charts and documents created. They will, of course, be searching for errors. These records are of great consequence in the legal process.
“The first thing a patient considering a lawsuit will do is request the medical records.”
Knowing that the patient will get the medical records should be motivation enough to make the records thorough and detailed. Remember, anything you write or record could be read in court. So when you chart in the medical record, think in the back of your mind that a judge or jury might both hear and see them.
“Anything you write could be read in court.”
2. Strive to document in the most comprehensive and detailed way possible. Time restraints are the biggest obstacle between a nurse and thorough charts. With the busy nature of the job, sometimes nurses are forced into leaving documents incomplete, or they make only vague notes.
It can take years for a lawsuit to culminate; it is unlikely that 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 write and record enough information to recall the specifics of the case, or at least what your usual and customary practice would have been in the situation.
3. Stay on top of your nursing charting. Sure, you may need to put off fully completing some charts on particularly busy days, but try not to wait too long. The longer you wait to fill out the necessary paper work, 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. Don’t just note what was abnormal in a case, record the commonplace, typical events in a patient’s care. It could be the normalcy of your treatment – the fact that you followed basic protocol – that helps you avoid getting sued.
4. Check all items and fill in every blank space, every question, every box on each form for which you’re responsible. Again, don’t think that you’ll be able to remember the details of the care given down the road if you don’t properly document. Even if it seems obvious or mundane, make a note of it.
If you’re unable to fully complete your orders for a patient’s care, be sure to note that. For example, if a patient is sleeping when you check in on them, don’t simply leave certain areas of their chart incomplete. Note the circumstance as to why the document isn’t fully complete (i.e. “patient is sleeping, therefore did not check temperature”) so you cannot be accused of deficient care later.
“It’s better to write too much in your charts than to write too little!
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.
5. A fundamental aspect for healthcare providers named as defendants in a lawsuit is the ability to recall. Sometimes this is years after caring for a patient and the details of a case even after examining your notes from the charts is hard to do accurately. The more information you include in your charts, the easier it will be for you avoid being unfairly accused.
Look For These Entries In The Medical Records
You’re looking to see the four basic elements in the nurses’ documentation: Assessment, Plan, Implementation, and Evaluation. Whether you’re reading the Nurses’ Notes, Medication Administration Record (MAR), or Nursing Care Plan, watch for these basic elements. The more complete the nursing care record, the greater the chance the correct care was provided.
Whether you’re approaching it from the plaintiff or defense side of the case, these principles apply. Remember, while you’re focusing on the case from your perspective as a legal nurse consultant, you’ll need to consider the strengths and weaknesses or opposing counsel’s case. That’s what makes your Professional Legal Nurse Consultant services even more valuable. It’s your ability to spot issues and bring them to the lawyer’s attention.
You’ve been trained as a nurse and a Professional Legal Nurse Consultant. That’s quite an impressive combination! Rely on your legal nurse consultant training and your nursing education as well as your experience to explore all aspects of the patient’s medical record before you draw conclusions.
Looking at the clinical care that was provided to the patient, does it meet the nursing standard of care? Does it fall short or does it exceed it? You’re in the best position to determine this from reading the notes. The nursing entries should be contemporaneous with the event but consider that they might be anecdotal. It’s yours to decide.
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