Court Appearance and Importance of Documentation

This article describes a situation encountered while working in a remote native community in northern Canada. You never know when you may be called to court to answer why you treated a client in a particular manner. It may be up to a year after the incident when your case reaches its court date. Don't forget that, 'if you didn't chart it, you didn't do it!

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Court Appearance and Importance of Documentation

Working in Remote Areas

While working for Health & Welfare Canada as a community health nurse, I received advanced training for outpost nursing at Dalhousie University in Halifax, Nova Scotia. In our training, we were taught the cardinal signs for assessing each body system as well as how to treat emergency cases such as pneumothorax, childbirth, intussusception, etc. This allowed us to communicate with doctors in 'their language' to describe client conditions and receive direction for treatment. The Northern native communities I have worked in receive a doctor's visit one day every six months. The doctor sees the clients that the nurse's cannot diagnose. As a nurse in one of these communities you assess, diagnose, and treat the client. I was 'on call' one evening when a young mother brought in her infant.

I pulled the patient chart and noted the infant had been seen the night before and was put on antibiotics. The client was lying in his mother's arms, he looked to be 3-4 months old and was very lethargic. I asked the mother how he was eating, and she replied that he had only had approximately 5 ounces of formula that day. I then asked what she was feeding him, thinking it would be enfalac, similac or some other acceptable commercial infant formula. When the mother answered 'coffee mate', I felt my stomach drop (listen to your gut instinct). I opened the lid, and when I put my nose to the bottle, I retched - it was putrid smelling. I instinctively tried to feed the infant electrolyte water in hopes he would receive some nutrients, but he had no energy to drink.

Failure to Thrive

I asked how old the baby was and her answer caused an uneasy feeling in my chest. I was shocked when she replied that he was a 'year old'. I plotted his height and weight on the growth and development chart to see where he was on the chart. The results showed 'failure to thrive' and this is considered very significant and warrants further medical investigation. I informed the mother that I wanted to send her son to the hospital in the city to get checked by a doctor. I had her go home and pack while I arranged a plane to transfer them. I kept the child at the nursing station because the mother voiced she didn't want to go to the city and this child needed further medical attention. I had to ensure they would get on the plane. I drove them to the airstrip and gave the medic on the air ambulance a report, the reason for the transfer and the paperwork. I was relieved when they were on the plane and transported to the hospital. I had heard that he was admitted to the hospital with a severe electrolyte imbalance and that was the last I had heard of the situation.

Investigation

About six months after the incident I was informed that there was an investigation into the case and that I was scheduled for an interview with an officer. The entire interview was taped. They wanted to get my perspective on what happened that day the infant was brought into the nursing station (this was very stressful).

Court

Months later I received a subpoena to appear in court as the infant had died. I had to get time off work, fly to the city where the case was being tried, and appear in front of the judge. It was hard to remember all the particulars of that day. By the time I was called to the stand, it was over a year from the date of the incident.

I was thankful they allowed me to look at my documentation to refresh my memory. The notes were all blacked out except my entries so I could not read what others had written. My documentation allowed me to remember the situation and the actions I had taken that day. I 'swore in' on the bible and then the questions started about why I sent the infant while the nurse the night before had not? I replied that I was not sure why the nurse or the doctor that was following this child made the decisions that they did. I can only answer for myself and that the child was diagnosed as 'failure to thrive', he was lethargic and being fed an inappropriate diet.

Lessons Learned

This infant died from severe electrolyte imbalance which could have been prevented if the infant was provided proper nutrition. Without the proper documentation of your assessment and the interventions you provided, you may be in a situation where your licence is on the line (if you didn't chart it, you didn't do it). You are accountable for your nursing decisions, actions, and documentation. Documentation provides communication between healthcare professionals to ensure everyone is aware of the client's condition and the actions taken to ensure safe care.

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Quantum Doctor

About Quantum Doctor

Robin Lambrecht, has a Masters degree in Nursing from The University of Southern Queensland in Australia and is currently taking her Doctorate in 'Integrative Medicine".

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Specializes in Allergy and Immunology.

Your story is an excellent reminder of just how important our documentation is. Thank you for sharing this story. So sorry to hear about this poor baby though. That is tragic. But, you did the right thing. We can't always have a positive outcome.

My philosophy with charting is to document as if any charting could go to court. And I ask myself, "if this did go to court, is it sufficient enough to ensure I rendered safe and proper care?" If not, I try to be very clear and concise, so there is no question about the care I provided.

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Specializes in Healthcare risk management and liability.

My Risk Management 101 statement on charting is: if it isn't in the chart, it didn't happen.

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Coffee Mate?!?

:no:

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Specializes in NICU, PICU, educator.

I've been to court on several occasions, best bet is to chart like you are going to court tomorrow.

Poor baby, we see cases like this in our PICU and it is sad :(

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Specializes in Family practice, emergency.

I just need a second to pull my heart out of my boots... It must have been miserable for you, I hope you are doing well.

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That's just awful. Poor baby. I wonder was it simple ignorance by the parents, lack of resources, or simple disregard for their child's life. I get too wrapped up in the "why's", trying to make some sense of something so sad.

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Specializes in Complex pedi to LTC/SA & now a manager.

Perfect answer when asked to comment on the choices of other staff member since you were only there to testify on your assessment and actions.

I've heard soy milk, cow milk, but coffee mate? That's not cheap!

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Specializes in NICU, PICU, educator.

We had one mom who fed her baby concentrated formula twice a day. She figured it was okay since it was extra fortified if you didn't dilute it. I've heard just about everything...

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Specializes in Critical care.

My peds ED experience as a student brought me to meet a young mother with very little resources. Her infant had been sick some months back and a call to "phone a nurse/doctor) led her to a brief trial (ie over the weekend) of half-strength formula.

Fast fwd to her little guy listlessly lying on an ED gurney as someone inserts a gastric tube. Pale formula is aspirated, which prompted questions about his feedings. Labs were starting to roll in about this time too. Sodium was 108... Mom had been feeding half-strength formula for 3 months.

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Specializes in Complex pedi to LTC/SA & now a manager.
BittyBabyGrower said:
We had one mom who fed her baby concentrated formula twice a day. She figured it was okay since it was extra fortified if you didn't dilute it. I've heard just about everything...

I can almost understand that thought process.

But rancid fake coffee creamer?

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RiskManager said:
My Risk Management 101 statement on charting is: if it isn't in the chart, it didn't happen.

I work in a med mal defense firm, and my boss pushes the exact opposite: just because it wasn't documented, doesn't mean it wasn't done. It comes up in depositions a lot, especially where we have assessments from our ER docs that were essentially left blank. A lot of them will later say that even though the form wasn't completed, they still did it, etc. and that sometimes they don't have time to complete the chart, especially in an emergent situation.

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