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Discussion

Failure to Chart?

This situation was presented during nursing class. I don't understand the failure to chart - yes, the nurse should have charted but couldn't pt sue anyway? And if both sites are acceptable, but greater risk for one than the other, why ever use the other?

Since the purpose of the chart is to document the care administered to the patient, how can a nurse convince other that care was provided if it is not documented in the health record?

A nurse, by habit always administers an intramuscular injection in the ventrogluteal site (although both the ventrogluteal and dorsogluteal sites are within the accepted guidelines of care). The nurse however, fails to chart the site on the medication administration record. The patient files suit for sciatic nerve damage. Knowing that there is an identified greater risk for sciatic nerve injury with the dorsgluteal site, do you think it would be difficult to defend the care given in this case?

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Like I said, it was just my guess. I'm no lawyer and I've always heard the burdon of proof is on the one doing the suing.

Where I work, the doc does have to order if a med is to be given IM, PO, SC, etc., but they don't order the site if IM or SC. I don't know if this is how it's done other places.

If this went to court, they would probably (just my guess again) bring in the medical record and it would show how the doc ordered it.

The burdon of proof is on the person filing the suit. This is for all legal matters not just medical malpractice. They must show proof of damage.

In a legal nursing course that I took several years ago, we were told that a nurse's testimony of 'I know that is how I did it/ where I gave the injection because I always do it that particular way/give it in that particular location' is acceptable as proof.

I still go by the CYA method of documenting.

FYI

Nurses are perceived by the public to be very honest and forthright.

on the floor i work on, we debate the whole charting issue often.

And no, the MD does not have to write where the injection is to be given, unless he/she has a specific reason for wanting/not wanting the injection to be given in a certain site.

Exactly, just like the many times they will write for no b/p or sticks to a particular limb (for whatever reason. One that comes to mind is hemodialysis graft sites).

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