The clinical record: recognizing its value in litigation

Documenting completely and accurately is standard nursing practice, yet many nurses do not seem to understand that proper documentation is crucial to the communication and critical decision-making necessary to meet patients' needs. In fact, failure to document can have lethal consequences. Documentation of intake and output (I & O) is used here as an example of the evidence attorneys and nurse experts look for in the clinical record of elders. From exhibits of I & O records, juries can determine if nurses collected sufficient data for appropriate decision-making to protect the patient from harm. Readers are invited to test themselves to determine if their own I & O documentation meets acceptable standards of nursing practice. If readers find areas for improvement, self-study or group in-services can be held to improve the documentation and use of these data.