Should you document a patient's exact words?
October 1, 2009 2 minutes read
Should you document a patient's exact words?
An emergency nurse was named in a malpractice lawsuit, accused of failing to protect a patient by allowing her fall out of a geriatric chair.
"The patient was particularly difficult and demanding. The nurse would not give into the patient's every whim," says Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and legal nurse consultant.
The patient became irate and told the nurse that if she failed to do what the patient wanted, that she would "throw myself onto the floor and hurt myself and you will be sorry. I will make you pay." "Subsequently, the patient did exactly what she said she would do, and the first opportunity she had to throw herself from the chair she did," says Ridgely. "Fortunately for the nurse, she had documented every word the patient said and had reported the interaction to her nursing manager, who also documented the information."
The patient was unaware that the nurse had documented the interaction and filed a lawsuit a year or so later. "The case went to trial and the jury found in favor of the nurse and the hospital. The patient did not receive a verdict in her favor," says Ridgely.
Quote marks can help
The use of quote marks by an ED nurse "could add value to the documentation," says Mariann Cosby, MPA, MSN, RN, CEN, LNCC, principal of Sacramento, CA-based MFC Consulting, a legal nurse consulting company. Cosby also is a practicing emergency nurse. When documenting a person's chief complaint at presentation to the ED, it is preferable to use quote marks and list the complaint in the person's own words as transcribed from the sign-in sheet or stated by the patient, she says.
"Since the chief complaint sets the stage for the triage nurse to begin the process of determining the person's acuity, having this accurately recorded is an important factor as the wheels are set in motion for care delivery," says Cosby. "It also makes it very clear what the patient conveyed on presentation and could be used to refute an argument that the nurse was told otherwise. However, the nurse is still responsible for exploring the chief complaint, in order to determine the most appropriate triage category."
For other documentation entries, using quote marks makes it clear that the documentation entry is not the nurse's interpretation of what the patient is saying, but rather, the patent's exact words. For example, if you provide a specific instruction as part of your discharge instructions, document the patient's response, such as "Patient acknowledged discharge instructions and verbalized, 'Yes, I will use the crutches as instructed and keep all weight off of my right leg until I see my doctor.'"
"This could be helpful in an alleged poor care situation," says Cosby.
Source
For more information on ED nursing documentation, contact:
- Mariann Cosby, MPA, MSN, RN, CEN, LNCC, Principal, MFC Consulting, Sacramento, CA. E-mail: [email protected].
- Elisabeth Ridgely, RN, LNCC. Phone: (610) 496-8610. E-mail: [email protected].
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