A suit was prevented with this documentation
A patient presented to an ED with a foreign body in her foot, but the ED physician didn't find anything even after doing an X-ray and exploring the wound. The next day, the radiologist read the X-ray and saw a foreign body. The patient later pursued legal action against the ED doctor and claimed there were no proper instructions for follow-up care.
However, the patient was not successful in this claim, due to an ED nurse's clear documentation of the instructions given to the patient during the first ED visit, and also a phone call made to the patient the following day. "My documentation saved the hospital and the physician being sued for not giving the patient appropriate instructions," says Christine Macaulay, RN, MSN, CEN, nursing practice and safety specialist at The Children's Hospital of Philadelphia. Here are documentation tips:
• Don't put yourself in a position of testifying about things you did, but failed to document.
Debra A. Gray, RN, MSN, LNC, principal of Gray's Analysis, a Beaverton, OR-based legal nurse consulting firm, says, "Too often, important details are not documented in the medical record."
In the event of a deposition or trial, your testimony should be based primarily on the information provided in the patient's medical record. "You may testify regarding undocumented care provided," says Gray. "However, your credibility can be compromised, if what you did or said is not accurately documented in the patient's medical record."
Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and legal nurse consultant, says, "It is amazing how many charts I have reviewed on patients who were in the ER for six hours or more, and there is one line of notes and one set of vital signs."
It is extremely hard to defend your actions if it appears that you did nothing for the patient, says Ridgely. "Your credibility will be destroyed by the opposing counsel," she says. "Even though you may have done everything right, if you didn't document what you did, you do not have a leg to stand on. "
• Make sure what you write is legible.
"Your documentation is supposed to be a communication tool," says Gray. "You'll want the jury to see you as an effective and professional communicator to other health care providers who subsequently care for the patient."
• Don't rely on preprinted forms or computerized records.
"Some nurses have mistakenly come to depend upon checkboxes and templates as their only documentation, to save time in a busy ED," says Gray. "This can make a medical malpractice lawsuit very difficult to defend."
To avoid this, Gray advises these two practices:
— If a preprinted form has instructions for its use, read and follow those instructions.
— Describe and elaborate upon positive findings in an additional note, as appropriate.
• Chart the time that you make each assessment.
With this charting, says Gray, "the timeliness of your actions is clearly delineated, and your entries are less likely to be contradicted by what others have written."
• Refrain from making negative comments if the patient is noncompliant during your assessments and interventions.
"Chart it, but be careful not to mention 'negative' things about his personality as a stand alone," says Teri J. Cox, RN, MS, CLNC, president and owner of Point Pleasant, NJ-based TCK Consulting, a legal nurse consulting firm and former director of emergency services at Bellevue Hospital/New York University Medical Center in New York City. "A good attorney will say you didn't like the patient and that is why you gave them substandard care."
Don't hesitate to add late entries to the chart Christine Macaulay, RN, MSN, CEN, nursing practice and safety specialist at The Children's Hospital of Philadelphia, says in cases she reviews involving emergency nurses, there often is "very scanty documentation" about the patient. "Nurses will say that the care of the patient always comes first," she says. "We are not saying you need to put documentation before your patient, but you can go back and put a late entry in." Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and legal nurse consultant, recommends rereading your documentation before your shift ends to see if it makes sense. "It is understood that ERs are busy, and it is understood that you may not be able to document concomitantly," she says. "However, there is no excuse not to document prior to the end of your shift." Late entries should be done, however, in a reasonable amount of time. "Waiting two weeks to document an event is unacceptable, and your credibility will become an issue," says Ridgely. Making late entries to your patient's chart might be time-consuming, she says, "but so is a lawsuit, and a lawsuit is much more draining and devastating to you as a nurse. Take the extra 15 minutes to document." |
Tempted to alter a chart? Never do so You could lose your license — or worse Removing or destroying documentation about an incident, adding to the notes from another health care provider under that provider's signature, charting entries out of sequence to cover up a delay in providing care, adding in vital signs and neurological checks that were never done, adding specific follow-up instructions that were not given to a discharged patient, or replacing a portion of an EKG strip with another patient's. It doesn't matter which of these practices is at issue. The bottom line is that you should never alter a record after the fact. "If this comes out in a trial, your credibility will be ruined with the jury, and they won't believe anything else you say," says Teri J. Cox, RN, MS, CLNC, president and owner of Point Pleasant, NJ-based TCK Consulting, a legal nurse consulting firm and former director of emergency services at Bellevue Hospital/ New York University Medical Center in New York City. Tampering is "impossible to defend," says Debra A. Gray, RN, MSN, LNC, principal of Gray's Analysis, a Beaverton, OR legal nurse consulting company. "Even a defensible case is usually settled early. The typical jury response is anger and large awards that often seem out of proportion to the actual damages or injuries sustained." Furthermore, if fraud is pleaded and punitive damages sought, you could lose the right to insurance coverage. "Most insurance policies do not cover punitive damages," she warns. "You could lose your professional license and your reputation in the community. Some states impose criminal sanctions." |
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