Minimizing litigation risk. Documentation strategies in the occupational health setting

When advice is given by telephone, nurses are relying on employees' or clients' own assessments of situations. Nurses do not have the benefit of examination and objective findings. Therefore, every occupational health practice should have a system for keeping a record of telephone calls. Noncompliance should be documented so the nurse is reminded of the need to consider compliance when caring for the client in the future. Documentation of report tracking and follow up, consent, client education, and discharge information contributes to improved quality of care and reduced risk of litigation. Client records should never be altered (i.e., changed) so the original entry is no longer visible. The SLIDE (Single Line, Initials, Date, Explanation) rule should be used.