The nursing shortage: the legal impact on documentation

In 1985, two significant events occurred in the health care industry. These events ultimately proved to have a deleterious effect on the nursing profession. In an effort to contain spiraling health care costs, the federal government implemented a reimbursement system based on diagnosis related groups (DRGs). One of the major foci of this system was the length of stay, i.e., the shorter the stay, the greater the monetary profit for the institution. Therefore, patients were being admitted and discharged "sicker." These two events resulted in nurses being torn between the need for adequate documentation and the delivery of patient care. When one adds to this mix the legal environment in health care, with its focus on the adage "if it is not documented, it was not done," nurses were becoming increasingly frustrated and frightened. In light of current legal trends, this article reexamines this adage and discusses implications for the nurse educator.