I recently testified in a personal injury case. It was quite an experience! A claim of a patient's family that she was injured by a cot that fell over and hurt her foot. It sounded like BS but after prepping for the case I started to think I may have done something wrong. The jury didn't think so and she got nothing.
This taught me an important lesson though. No matter how minor something seems, keep a good record of what happened. This incident was almost 9 years ago! I've forgotten a lot of useless stuff since then.
It would be interesting to hear other nurses experiences with the legal system
I am curious as to when they initiated the lawsuit. The reason I ask is because in MN we only have to keep records for 5 years, unless there is an active suit going on then we keep them 9 years after the case was settled.
My first contact was oin 2004. Mistrials, adjournments and other legal mumbo-jumbo delayed it! The plantif's lawyer speant over $30,000 on expert witnesses and I know he won't get it back from her. She was on record as saying she was waiting for her big payday. Now all she has is debt and hopefully guilt that she tried to defraud the system.
This just happened the other night. Patient confused and refusing meds. Seems she has been doing this for a couple of days. No one charted but me on her behavior. I wrote a book, even included the sitters comments. Got a message from head honcho on the machine to say thanks, family finally approached staff about her behavior and was given to understand from the notes they knew she was refusing meds, even remarked to sitter if she did not start doing better she was not coming home. Sitter affirmed comments, so maybe suite will be avoided. Why other staff did not chart is beyond me but I CYB myself.
This just happened the other night. Patient confused and refusing meds. Seems she has been doing this for a couple of days. No one charted but me on her behavior. I wrote a book, even included the sitters comments. Got a message from head honcho on the machine to say thanks, family finally approached staff about her behavior and was given to understand from the notes they knew she was refusing meds, even remarked to sitter if she did not start doing better she was not coming home. Sitter affirmed comments, so maybe suite will be avoided. Why other staff did not chart is beyond me but I CYB myself.
my boss brought me in honey bran muffins x 1 wk, r/t my meticulous notes, which happened to save the facility's hide.
on the flip side, last yr i noted something r/t what a pt had told me...
they were suspicious concerns about another nurse and the meds the pt was supposed to be taking.
i documented pt's concerns and boss did not like it one bit.
long story short, this nurse had been diverting, and the only reason it was discovered, was through pt's suspicions and my subsequent notes.
point being, whenever there is potential for disgruntled customer, i note it.
They don't expect you to remember it. It should be in the chart. It has always been beat through my head how important documentation is. I hope I am never in this situation but I also hope if I am my documentation will back me up.
It's a case (10 years ago) that makes me worry even more about computer charting. I do not believe it's possible, with all the little drop-down phrases and all, to make a complete picture of what was done.
It's a case (10 years ago) that makes me worry even more about computer charting. I do not believe it's possible, with all the little drop-down phrases and all, to make a complete picture of what was done.
That's why you shouldn't only rely on the little drop down phrases and all, but you should also type notes and comments just like you would if you were paper charting, I see no difference.
noc4senuf
683 Posts
I am curious as to when they initiated the lawsuit. The reason I ask is because in MN we only have to keep records for 5 years, unless there is an active suit going on then we keep them 9 years after the case was settled.