Research question on malpractice and nursing documentation

[I will be a nurse]

Hi,

So I am in nursing research this quarter and am writing a research paper on nurses being sued based on their documentation. My first question is What are the most common mistakes nurses make when documenting that end up leading to malpractice suit? What are things that nurses can do to improve their documentation legally?

Any help on this would be awesome. If anyone knows of any lawyers who would also be willing to share on this topic would be great!!!! Thank you so much!!!

[NRSKarenRN, BSN, RN]

Some resources to get you started:

Should I Carry Malpractice (Liability) Insurance?

RISK MANAGEMENT AND LEGAL ISSUES - Jones & Bartlett Learn

Protecting yourself from malpractice claims - American Nurse Today

Professional Liability - Nurses can take action to reduce liability risk

Legal Eagle: Court Says Charting Only Abnormal Findings Is Unacceptable

[classicdame, MSN, EdD]

you will need to do some searching in CINAHL but it is my understanding that the most common error is FAILURE to document what occured and when.

[nurseprnRN, BSN, RN]

You can also contact your state board of nursing and see what disciplinary actions regarding documentation have been handed down in the last few years.

Not to be cranky, but asking us to give you the answers is not going to work. You need to do more digging than just asking us to do your homework. Don't take it personally-- we tell everybody that :). We say, "Where else have you looked? What have you found already?" Your post makes no mention of any of that.

But it does ask for help, and you have rec'd some good sources to go find your answers. When you're done, consider posting an article here on your findings, to enlighten other students.

[I will be a nurse]

So I'm not asking anybody to give me any answers. My assignment on this research project was to get information from RN's what they notice are common errors made while documenting. My part in the project was to go to different sources like facebook, blogs, etc. to find out what people think about the topic. I expected this to be a wonderful outlet for information since this is supposed to be for nurses helping other nurses and soon to be nurses, not someone to critique my post saying I'm asking people to do my homework. Maybe you should have looked at it as a research survey or I should have made that more clear. I have so many scholarly journal articles and have done so much research on the academic aspect but I need a real world aspect for my research. I do take it personally because this is the one spot that I thought I would get help and not reprimanded.

[Double-Helix, BSN, RN]

A "research paper" in college generally indicates that your instructor expects you to use reliable sources for your paper. Reliable sources are professional, peer-reviewed studies. Not opinions from an internet forum.

If part of your research project is to survey social media and anonymous forums about this subject, then you're absolutely right that it would have been helpful to state that in your first post. I'm sure you can see how, based only from the wording of your original post, it might be perceived that you were asking us to provide you with research.

I'd really like to read more about malpractice lawsuits relating to documentation. Could you please link some of the articles you've found? It sounds like a very interesting subject.

[Double-Helix, BSN, RN]

Oh, and here's some of my opinion to help with your project.

The most common problems I see are failure to document at all, failure to document follow up (ex: patient's chart says patient has a fever of 102- no documentation of actions take, physician notified, reassessment, etc.) and documenting without performing an assessment.

The best example I have of documenting without performing an assessment is when I admitted a child for observation following a tonsillectomy. When I auscultated heart sounds, the child had a loud heart murmur. I lifted her gown and saw a midline sternotomy incision indicating past open heart surgery. The father, who did not speak English well, could only tell me that she had surgery for her heart when she was younger. I looked back through the documentation from the pre-op nurse and there was nothing documented about the heart condition. Previous surgeries documented as "None." Heart sounds documented as "S1, S2, no abnormalities." In short, this child could have had a serious congenital heart defect that made anesthesia, certain medications, and surgery much more risky and may have resulted in complications. Had something like that happened and gone to court, the pre-op nurse would have been nailed to the wall for documenting a normal assessment when the assessment was obviously not performed.

[KelRN215, BSN, RN]

I wouldn't really say that nurses get sued based on their documentation but, rather, that a case goes to court because of something that happened and if the documentation is lacking, it's not helpful to the case. I've had many cases that I've assumed could have gone to court. A nurse I used to work with would always say "you document for one person- THE JUDGE." A former colleague of mine was on a jury for a case that involved a woman who'd been hit by a city bus and he said the nurses' notes were critical to the case. The defense went out of their way to find the shoddy ones... the ones that said this woman was independent with her ADLs and was progressing towards her baseline, etc when she wasn't at all. I took care of a patient who was a victim of the Boston Marathon bombing earlier this year and every time I wrote a note on him, all I could think was "these records could get subpoenaed". Nothing with my documentation could lead to me having legal problems but the records could easily be requested as evidence of the damage done by those bombs...

[I will be a nurse]

I understand that I should have been more clear in the first post, but it was NEVER my intention to ask anyone to do my homework. Trust me I understand that a "research paper" is usually peer-reviewed scholarly journal articles, so when I was assigned "new research" I thought that was interesting I am interviewing a lawyer and gathering information from just real life. I have read many research articles but have yet to see "new research" but hey she has her doctorate and I'm just a student :) What type of articles would you like the scholarly journal articles???? I guess we are also sending our paper to a publisher so as soon as that goes through I will be happy to share it with everyone. Thanks also for sharing your experience, I'm really learning how important proper documentation is

[Esme12, ASN, BSN, RN]

They only issue most nursing scholars have with AN....and believe me many of us are nursing scholars and might be your instructors...is that it is an anonymous site you have NO IDEA who you are speaking to and whether or not they are even nurses.....therefore we are not a "reliable" scholarly source. A simple Google search can give you many results. I am sure your school has covered what a reliable source is.... as well as give you access to scholarly resources.

What are the most common mistakes nurses make when documenting that end up leading to malpractice suit?

Let me google that for you

What are things that nurses can do to improve their documentation legally?

Let me google that for you

We cannot recommend attorney's as per the Terms of Service....The American Association of Nurse Attorneys www.taana.org

You might also try.....American Association of Legal Nurse Consultants (AALNC)

Our job as educators and professionals is that you learn...we are happy to help. However...it is our obligation to help you become the best nurse that you can be. A part of a nursing research course is not just about the paper you write but about learning how to conduct research on your own and weed out the nonsense.

Us Nurses...we don't know everything and we may not have all the answers....but we do know where to find it amongst reliable sources.