Often reading threads on here leads me to Google searches, and a bit of online research/reading. I just landed on this
site, and came across this.
All in all an interesting read. But, I think I better up my insurance, and do something to protect my ass(ets). Apparently, my charting is not up to snuff.
25 LEGAL DOs AND DON'Ts OF NURSING DOCUMENTATION
1. "If you did not write it down, you did not do it. If you did not do it, youwere negligent." You need not just to chart what you did but how youdid it. Otherwise, how will you testify years later, with no actual recollection of the patient in question, that you did it right? For example:"ketorolac 20 mg IM" versus "The appropriate injection site in the gluteal muscle was located by reference to the patient's iliac crest. Then theinjection was administered into the muscle tissue using a pre-filled 30 mgsyringe with a 1 ¾ inch 18 gauge needle, after having attempted unsuccessfully to aspirate blood upon insertion of the needle. No complains of numbness or tingling in the lower extremity. 10 mg of the medication was wasted." What if the patient sues five years later claiming a sciatic nerve injury from your injection technique - which of those two progress notes do you want to have with you on the witness stand? The first one gives you no positive basis to testify that you did the injection correctly, and it is basically a toss-up whether or not you will be found liable.
Last edit by Brian S. on Jun 26