I recently was involved in a medical malpractice trial in which the nurses’ documentation was at issue. Or perhaps more appropriately would be to say it was the nurses’ lack of documentation. Sometimes we get so busy with our work, but documentation is the only thing that may save you if there is a medical malpractice action.
Many States have a statute of limitations which is a timeframe setting up a deadline for when a lawsuit can be filed. Here, in Indiana, that statute limitation is 2 years.
If the action is filed within that 2-year period, you may not know of it until later, sometimes even several years. This particular case we just completed took 10 years to come to trial.
With that length of time between the incident and the trial, the nurses did not remember all the facts in the case and could rely only on their documentation, which was found to be wholly lacking.
It is embarrassing to be a nurse on the witness stand, as with this case, and asked why documentation was not signed or initialed. Also embarrassing is if a physician writes something that contradicts your own notes.
If that were you, how would you stand up for yourself? How would you defend your care?
Your documentation will save you every time. The more you write and the more thorough you are will help you down the road, specifically to jog your memory about your care in that matter.
Saying that you always do something, while helpful, comes with the understanding that, as the saying goes, “If it’s not documented, it wasn’t done.”
With electronic charting, which is supposed to be a time saver, I know it can be more cumbersome. Don’t be afraid to write narrative notes.
It also is a good practice that in six months to a year from now, you take the time to look at some of your previous records to verify that you really did document them to the fullest extent. Also, test yourself to see what remember about those patients.
Though it is not very likely a patient you care for will end up as a litigation matter as very few end up on that road. Regardless, take that extra time to document.
Remember, you not only protecting yourself and the facility, but also guarding your license as well.
Judy Martin-Morgan says
For clarification are you suggesting / saying while checking your charting 6 months later it is okay to make additional notes or corrections?