I am doomed.

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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.

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Specializes in Private Duty Pediatrics.

This brings back nightmares of my student nurse days! :woot:

In the example above, I would most certainly go with the first entry, as long as it also included the injection site. (And no, I surely would not describe HOW I ascertained that I had correctly located the site. :rolleyes:

Oh, the memories!

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Specializes in Critical Care and ED.

Who has time for that? Luckily with Epic you're click click click done.

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Well, if this genius would simply like to note that the medication was given in the VG, it's a pretty safe bet that the sciatic was not involved. Then, when asked how one knows it went in the VG, one describes the proper technique and testifies to always using said technique. That's how you know what you did.

We should document equally as thoroughly about everything, such as taking a simple set of vital signs. That would be hilarious. "Thermometer positioned under the tongue adjacent to the left lingual frenulum and patient instructed to close lips around the probe..."

Maybe go to these folks requesting their professional services for advisement on legal documentation. Maybe you can sue them when you get fired for spending most of the day writing a novel?

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Specializes in Nurse Leader specializing in Labor & Delivery.
Well, if this genius would simply like to note that the medication was given in the VG, it's a pretty safe bet that the sciatic was not involved. Then, when asked how one knows it went in the VG, one describes the proper technique and testifies to always using said technique. That's how you know what you did.

This, exactly.

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Specializes in ER.

An 18 g needle for an IM? Yikes!!! :wtf:

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Specializes in Emergency, Telemetry, Transplant.

What if the pt comes to the ED in a few days and says "the nurse who gave me this IM injection caused this infection on my leg." Heaven forbid you didn't chart--"the area was swabbed with alcohol. Before swabbing I checked to make sure that the alcohol pad was not expired. I also went online and looked up the lot number to be certain that the supplier did not issue a recall on this batch. I allowed the alcohol do dry completely. I then removed the cap from the needle. I had previously checked, and the expiration date on the needle was 02/2024. I was certain to make sure I did not touch the needle with my gloved hand. In addition, I made sure that the exam room door was shut so that there was no abnormal air flow into the room which may have contaminated the needle. To be certain, I called EVS first to shut of the vent to the room to further prevent any risk for infection by pathogens that might be introduced into the room by this route."

After that you can move on to an IV insertion in a different room. That should only take 90 min or so to chart....

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What if the pt comes to the ED in a few days and says "the nurse who gave me this IM injection caused this infection on my leg." Heaven forbid you didn't chart--"the area was swabbed with alcohol. Before swabbing I checked to make sure that the alcohol pad was not expired. I also went online and looked up the lot number to be certain that the supplier did not issue a recall on this batch. I allowed the alcohol do dry completely. I then removed the cap from the needle. I had previously checked, and the expiration date on the needle was 02/2024. I was certain to make sure I did not touch the needle with my gloved hand. In addition, I made sure that the exam room door was shut so that there was no abnormal air flow into the room which may have contaminated the needle. To be certain, I called EVS first to shut of the vent to the room to further prevent any risk for infection by pathogens that might be introduced into the room by this route."

After that you can move on to an IV insertion in a different room. That should only take 90 min or so to chart....

:roflmao:

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We should document equally as thoroughly about everything, such as taking a simple set of vital signs. That would be hilarious. "Thermometer positioned under the tongue adjacent to the left lingual frenulum and patient instructed to close lips around the probe..."

I'm really glad I hadn't just taken a big gulp out of my water bottle when I read that.

:D

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
What if the pt comes to the ED in a few days and says "the nurse who gave me this IM injection caused this infection on my leg." Heaven forbid you didn't chart--"the area was swabbed with alcohol. Before swabbing I checked to make sure that the alcohol pad was not expired. I also went online and looked up the lot number to be certain that the supplier did not issue a recall on this batch. I allowed the alcohol do dry completely. I then removed the cap from the needle. I had previously checked, and the expiration date on the needle was 02/2024. I was certain to make sure I did not touch the needle with my gloved hand. In addition, I made sure that the exam room door was shut so that there was no abnormal air flow into the room which may have contaminated the needle. To be certain, I called EVS first to shut of the vent to the room to further prevent any risk for infection by pathogens that might be introduced into the room by this route."

After that you can move on to an IV insertion in a different room. That should only take 90 min or so to chart....

This wins the post of the day award.

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What if the pt comes to the ED in a few days and says "the nurse who gave me this IM injection caused this infection on my leg." Heaven forbid you didn't chart--"the area was swabbed with alcohol. Before swabbing I checked to make sure that the alcohol pad was not expired. I also went online and looked up the lot number to be certain that the supplier did not issue a recall on this batch. I allowed the alcohol do dry completely. I then removed the cap from the needle. I had previously checked, and the expiration date on the needle was 02/2024. I was certain to make sure I did not touch the needle with my gloved hand. In addition, I made sure that the exam room door was shut so that there was no abnormal air flow into the room which may have contaminated the needle. To be certain, I called EVS first to shut of the vent to the room to further prevent any risk for infection by pathogens that might be introduced into the room by this route."

You, my friend, are on the hook for $5 zillion. "Tell me, Ms./Mr. psu_213, are you aware that hand hygiene should be performed prior to donning gloves? This record is devoid of any evidence whatsoever that you performed hand hygiene at any time during your encounter with my client. In fact, it doesn't even really tell us whether you were wearing fresh gloves or not, now does it! You refer to your 'gloved hand.' Please tell the court what you mean by that; and please do let us know on which hand you were wearing the one glove you mention! Are you this careless in performing all of your duties? For all we know, you performed this procedure on my client while wearing a filthy baseball glove - which, I don't think I need to tell you, completely explains the severe infection that has disabled my client!

"

:)

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I hate stupid lawyers. I used to date a couple. What does that say about me??? Ha!!!!

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