This document discusses the importance of thorough nursing documentation to protect against malpractice claims. It outlines the criteria for negligence claims - duty, breach of duty, causal relationship, and proof of injury. The document warns nurses about "red flags" in documentation like omissions, time gaps, and altered records that could indicate negligence. It provides guidelines for thorough nursing documentation, such as being specific, descriptive, objective, and including patients' own words. Proper documentation is necessary to show either an unfortunate accident or evidence of negligence if a malpractice case occurs.
2. Helping Nurses Stay in the Hospital and out of the Courtroom
Documentation can subject a nurse to malpractice claims
or protect against them
A Lesson for Acute Care Med/Surg Nurses
Understanding how the law applies
Protecting yourself from liability
3. Why Nurses, Why Now
Criteria for Negligence
Red Flags
Hurdles
Documentation Guidelines
4. Before: Doctors are professionals
Nurses are assistants
Now: Nurses are also professionals
(Weld, 2009)
5. Four Criteria of Negligence
Duty
Breach of Duty
Causal Relationship
Proof of Injury
(Frank-Stromborg, 2001)
6. Weighing In
Beyond a reasonable doubt Clear and convincing evidence
Preponderance of the Evidence
>50%
tips the scale
7. Omission of key facts
(Austin, 2006) (Croke, 2003)
Time gaps
Limited nursing assessments
Frank-Stromborg (2001)
9. Hurdles
Nurse/Patient Ratios
Emergent situations
Too tired/overworked
Too busy/not enough time
Not knowing how to chart
Not knowing what to chart
10. General Charting Rules
Be specific
Descriptive
Objective
Subjective
Normal and abnormal findings
Gruber & Gruber (1990)
11. Specific Examples
Reasons for omitted tx/rx
Patient’s own words
Patient’s response
No abbreviations
Just the facts
Gruber & Gruber (1990)
12. When In Doubt
Think Like a Juror
Unfortunate and unavoidable accident
OR
Due to
negligence
inadequate skill
poor judgment
Ferrell (2007)
13. Organizational Guides
American Nurses Association
Principles for Documentation, 2003
Joint Commission of the Accreditation of
Healthcare Organizations (JCAHO)
State-specific Codes (New Jersey)
(Monarch, 2007)
14. Point to Remember to Protect Yourself
Nursing documentation is a heavily analyzed portion of the
medical record in malpractice cases.
Use of computerized documentation systems does not
automatically protect a nurse from malpractice claims.
It depends on you
and what and how
you document.
15. References
A u s t i n , S . ( 2 0 0 6 ) .
“ L a d i e s & g e n t l e m e n o f
t h e j u r y , I p r e s e n t t h e
n u r s i n g d o c u m e n t a t i o n ” .
N u r s i n g . 3 6 ( 1 ) , 5 6 - 6 2 .
R e t r i e v e d f r o m
h t t p : / / w w w . n c b i . n l m . n i h .
g o v / p u b m e d / 2 0 5 4 3 6 4 8
C r o k e , E . ( 2 0 0 3 ) N u r s e s ,
n e g l i g e n c e , a n d
m a l p r a c t i c e : a n a n a l y s i s
b a s e d o n m o r e t h a n 2 5 0
c a s e s a g a i n s t n u r s e s .
A m e r i c a n J o u r n a l o f
N u r s i n g 1 0 3 ( 9 ) , 5 4 - 6 3 .
R e t r i e v e d f r o m
h t t p : / / w w w . n u r s i n g c e n t e r
. c o m / p d f . a s p ? A I D = 4 2 3 2 8 4
D e a r m o n , V . ( n . d . ) R i s k
M a n a g e m e n t a n d L e g a l
I s s u e s , J o n e s a n d
Editor's Notes
You are here today because you are a nurse in an acute care facility that incorporates electronics in its documentation system. We tend to think computerized systems are flawless, but their effectiveness and value is greatly determined by what we put into them. Our goal today is to help you understand the legal significance of your documentation.
We want to help make sure you stay in the hospital and out of the courtroom, and since the great majority of nurse malpractice payouts are against acute care med/surg nurses, we want to make you aware of how your documentation can subject you to malpractice claims or protect you against them. We will look into how the law applies and what you need to be cognizant of to protect yourself from liability.
More specifically, we will take a look at (1)why it is that nurses are now the subjects of malpractice claims, (2) the criteria for proving negligence, (3) red flags that attorneys look for in medical records, (4) the hurdles we face as nurses, and (5) some guidelines to remember to help improve how we document.
Why nurses? Why now? *Years ago doctors were the only professionals in healthcar. *Nurses were just assistants. They were only expected to “use such care as a reasonably prudent and careful person would use under similar circumstances.” (Weld, 2009). As the nurse’s role and responsibilities increased, so did the nurse’s education. *The nurse became recognized as a professional. With that recognition came liability and subjection to malpractice.
The are four criteria that must be established for there to be a viable malpractice claim. The first, referred to as a duty, is a recognized relationship between the nurse and patient where it can be shown that the patient requested or allowed care by the nurse and the nurse agreed to take care of a patient. Next it must be shown that the defendant nurse failed to provide reasonable care or meet the designated standards of care. This is called breach of duty, like not meeting your obligations under a contract. Third is causal relationship, which means that not only did the nurse not meet the standard of care, but by not doing so caused – or was a contributory cause of – the plaintiff/patient’s injury. Finally, the plaintiff/patient must prove the injury that was purportedly suffered as a result of plaintiff/nurse’s actions or inactions. (Frank-Stromborg, 2001).
Most people have heard the phrase * “beyond a reasonable doubt”. This is the most difficult to prove and is reserved for criminal cases. * “Clear and convincing evidence” may also be a familiar term to some, and it is the measure for certain types of civil cases. However, malpractice cases only require a * “preponderance of the evidence”, which is the * lowest level of proof in a trial. What this means is that if it is determined that the nurse was * greater than 50% at fault, the patient will have proven his case. This does not equate to the percentage of the nurse’s documentation that was wrong, missing, inconsistent or otherwise substandard, Rather, even if the* majority of the record contains full and proper documentation, if even one aspect is deemed to be * greater than 50% of the cause, * the proof is satisfied.
Nurses know in theory that they should be documenting everything they do, “if it isn’t documented it wasn’t done”. *Omission of key facts is a major flaw in documenting; one that sends up a red flag. Since this one is so important let’s consider two examples. *Consider a case where a change in a patient’s condition warranted doctor notification. The nurse’s documentation indicated the time the change of condition was detected, what the change was, and the time the nurse communicated the change in status to the doctor, which was over an hour later. *The nurse did not, however, document her “initial unsuccessful attempt” to reach the doctor at the time she noted the change. This one omission caused the nurse to lose the case in that it was the basis for the determination that she delayed notification. Other types of omission may be due to the mistaken assumption that certain things are too obvious or routine to include when charting. An example of such an omission can be found in a case where *an injection of the correct dose of the correct medication was given to the correct patient during an emergency room visit and the patient later claimed suffering a “cutaneous gluteal nerve injury”. The medical record did not contain any information as to how (subcutaneous or intramuscular) or in what part of the body the injection was given, so even though the nurse routinely gave this injection intramuscularly in a site where the plaintiff purportedly sustained injury, her lack of documenting this information made it impossible for her to prove she gave it properly in this case. She lost at both the trial court and appellate level. Clearly, determination as to whether the standard of care is breached relies heavily on the medical record. (Croke, 2003).*Time gaps and *limited nursing assessment are two more issues that raise red flags. If you supposedly do hourly rounding, or it is even every other hour that you see a patient, you need to document that you have seen them, what they were doing, what their general condition was, or even that there was no change since your last assessment or check-in with them.
*Altered records are usually seen as intentional cover ups. If a record must be altered because a true error is found that needs to be corrected, the explanation itself needs to be documented. Missing charting can lead to accusations of *Patient Abandonment. This is an example of the dogma “if it isn’t documented, it wasn’t done.” So even if you checked in on your patient every hour, if you only show a morning assessment and perhaps a med administration or two, that does not cover you for your shift. *Charting inconsistencies are obvious. It is especially easy to make this kind of mistake on electronic systems with drop downs to click on, and more so if you are in a hurry. You need to really read every box you check, or skip, and make sure it is consistent and makes sense with something like it in another section.
There are many on the road to complete and accurate documentation. Some of these are: (read list)However we cannot let these barriers, while undeniable, get in our way.
It’ not just how much you chart, but also how you chart. * “Bad charting will make a good nurse look bad.” (Gruber & Gruber ,1990). General charting rules to remember and take the time to follow are: (read list)
Always give reasons if something is not done. For instance, if a med is not given, state “insulin not required, blood glucose 110”; or if a hypertension med was not give, state “Blood pressure 90/50”. Whenever possible, and especially if something is being described or documenting an event, use the patient’s own words, and quote them.Always document the patient’s response to your intervention, whether verbal, gestural, or your physical assessment of the patient.Do not use abbreviations no matter how familiar they are to you or anyone in your unit or department.Be accurate and complete, but do not elaborate. Less can be more. So just give the facts.
If you get stuck on how you want to phrase something or whether or not it is needed or superfluous information, imagine you do not know the actual situation or circumstance and you are reading the information documented. Ask yourself what picture that information paints. If it is not clear or gives an inaccurate impression, adjust accordingly. If you did everything right, and your documentation shows that, it is more likely to be judged as an * unfortunate or unavoidable accident that was not your fault. If you do not paint an accurate picture, you may be deemed to have been * negligent, * not have necessary skills, or used * poor judgment, all of which adds up to malpractice.
There are no local, regional or national organizations that include in their purpose support to nurses regarding documentation or related liability. The only guides there are are Principles for Documentation, published by the ANA in 2003 and basic guides by JCAHO and individual State codes. None of these, however, address legal liability.
