Documentation: Your First Line of Defense against Malpractice Claims

**Nurses Service Org**

Though it can vary by state, typically the statute of limitations to file a medical malpractice lawsuit is two to three years. Though most claims are settled out of court, if it does go to trial, the average malpractice case takes 3-5 years to resolve.*

Now, take all the patients you see in a week, a year, three years. Then imagine being called to testify in a trial involving medication you administered a patient six years ago. Without documentation, it can be difficult to remember exactly what happened four months ago, let alone six years ago.

Regardless of whether you are using electronic or hand-written medical records, get into the habit of thoroughly documenting the file so any healthcare provider can clearly understand the patient's condition, treatment and all interventions you performed on their behalf.

When a malpractice claim occurs, your legal team uses the patient record to build a defense. If the documentation is absent, incomplete, or sloppy, it can reflect poorly on you and make it impossible to mount a successful case. Complete, accurate documentation will help you build a strong defense.

Practice These 3 Rules to Avoid Common Charting Mistakes

Check that you have the correct chart before you begin writing

While this may sound like common sense, if patients in the unit have the same name, same condition, or same doctor, it can often lead to confusion that causes charting errors. When you have two or more patients with the same name, a good tip is to make sure a different nurse is assigned to each patient.

Record all pertinent health or drug information

In a recent case, a nurse neglected to record her patient's penicillin allergy in the admission notes. An intern who wasn't aware of the allergy gave the patient a penicillin injection, causing them to go into anaphylactic shock and suffer irreversible brain damage. Forget to record a patient's food and drug allergies, diseases or chronic health conditions that caregivers need to know about, and you could end up in court.

Record all nursing actions

In another case, a day nurse observed heavy drainage from a surgical wound and changed the patient's dressing, but forgot to document it. When the evening nurse checked the notes and found no evidence the dressing was changed, she considered the amount of drainage normal for a period of several hours. What if the condition had worsened? No one knows whether to raise an alarm if each nurse's actions are not recorded.

These tips may also help you improve your charting

Chart promptly

As soon as possible after you make an observation or provide care, document your action. If you wait until the end of your shift, you could forget important information.

Check spelling and grammar

Misspelled words and poor grammar make an unprofessional impression.

Keep it neat

There is nothing worse than not being able to read your own handwriting. Illegible notes could lead to a patient injury.

Be concise

Avoid vague terms such as "appears" or "apparently" when describing symptoms. They make you sound unsure of your observations.

Use objective terms

Document the specific length, width, and depth of the wound or for a small wound compare it to a common object ("size of a penny").

Chart a patient's refusal

If a patient refuses to take a medication or allow treatment be sure to document it in the chart and report it to your supervisor and the patient's physician.

Avoid criticism

Don't criticize the patient and/or other caregivers. Most patients have the right to review their clinical records, so be professional.

Correct errors properly

If you make a mistake, draw a line through it and write "mistaken entry." Never erase an erroneous entry, which could appear like a cover-up.

No matter what you did, it is easily proven if clearly documented. If you want to stay out of the courtroom, document, document and document should be the mantra around all patient care activities.

*Chesanow, Neil, "Malpractice: When to Settle a Suit and When to Fight," Medscape, Sept. 25, 2013.