Documentation: Your First Line of Defense against Malpractice Claims

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    What medications did you administer a week ago? What were the doses? How about a month ago, four months ago, a year ago? How much can you remember? Your career may depend on it.

    Documentation:  Your First Line of Defense against Malpractice Claims

    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.

    8 Common Charting Mistakes to Avoid, Marianne DeMilliano, BSN, JD,
    Defensive Documentation
    Do's and Don'ts of Documentation
    Documentation on Trial: 9 Ways to Protect Your Agency
    Documentation: Proactive Prevention of Litigation, Barbara Resnick, PhD, CRNP, University of Maryland, School of Nursing

    This article is provided for general informational purposes only and is not intended to provide individualized business, insurance or legal advice.
    Last edit by Joe V on Jun 16, '18

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    3 Comments so far...

  3. by   smartnurse1982
    I am looking at the articles,and have a question on the below:

    . Failing to record that medications have been given

    Record every medication you give when it’s given--including the dose, route, and time.
    A day nurse gave a patient heparin by intravenous push just before she went off duty. An hour later, the evening nurse saw the order for heparin--but no indication that it had been given. So she gave the patient the same dose. The patient began to hemorrhage and went into hypovolemic shock. He recovered--then successfully sued the hospital.
    Both nurses made mistakes here. The first should have recorded that she’s given the dose. The second should have been suspicious when she saw the order for heparin but no evidence that it had been given. She could have:

    • asked the patient if he’d received the medication.
    • called the pharmacy to see if the dose had already been furnished.
    • called the first nurse at home.

    So always investigate when you suspect a medication may have been given but not recorded.

    First,how was the first nurse able to give the med without it being on the Pyxis or other computerized charting?
    Wouldn't there have been an alert that the med was pulled?

    Asking the patient is not always feasible,especially if said patient is drowsy.

    The other is..Call the nurse at home"?


    I do not know how any of this is the second nurse's fault.
  4. by   LadysSolo
    I am told by my employer that I document too much. Having had to give a deposition once, I now document so any attorney looks at my documentation and decides it is not worth it to sue me. I will NOT shorten what I believe is necessary documentation (I also want to be able to look at my notes if I ever AM sued and be able to remember who it was.)
  5. by   quazar
    Quote from LadysSolo
    I am told by my employer that I document too much. Having had to give a deposition once, I now document so any attorney looks at my documentation and decides it is not worth it to sue me. I will NOT shorten what I believe is necessary documentation (I also want to be able to look at my notes if I ever AM sued and be able to remember who it was.)
    Amen to that. I was told by a (now former) employer the same thing, and some younger nurses have said I document too much. I'll keep my heavy documentation, thank you very much. If I go to court, I want it to be CRYSTAL clear what happened/didn't happen on my watch.