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Nurse documentation: not done or worse, done the wrong way--Part II
M Frank-Stromborg1, A Christensen, D E Do
1School of Nursing, Northern Illinois University, DeKalb, USA.
Purpose/Objectives:
To focus on nursing documentation and how it can lead to a malpractice lawsuit.
Data Sources:
Nursing, non-nursing healthcare and legal journals, case law, and related Internet sources.
Data Synthesis:
To avoid liability for inadequate or inaccurate documentation, nurses must be aware of how their documentation can either lead to a malpractice claim or actually decrease their chances of ever being named in a malpractice lawsuit. Malpractice cases often are decided based on documentation. The only viable way to defend against allegations of professional negligence is accurate and complete patient charting or defensive documentation.
Conclusions:
By examining case law involving inadequate or inaccurate documentation, nurses will be able to effectively adopt documentation practices or policies to decrease potential litigation.
Implications For Nursing Practice:
Educating nurses about the principles of documentation and the importance of implementing risk-reduction practices will help guard against liability and ultimately improve patient care.
Related Concept Videos
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
01:10Documentation of Nursing Diagnosis
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
01:30Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:26Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:21Methods of Documentation III: PIE
01:06Legal Guidelines for Documentation