Legal Implications of Nursing Documentation in Obstetrics
1. Legal Implications of Nursing
Documentation in Obstetrics
Margaret Rhone Wood, Ph.D., R.N.
2. 2
Overview of the Presentation
1. CNO Documentation Standards.
2. Experts and their reviews.
3. Documentation is evidence. What
documents are we talking about?
4. Sources of nursing standards.
5. Sources of nursing liability.
6. The role of the hospital and insurers.
7. Summary and take-home message.
3. 3
Purposes of Nursing
Documentation (CNO)
1. Communication
2. Accountability for actions
3. Legislative requirements
4. Quality improvements
5. Research
6. Funding and resource management.
4. 4
Purposes of Documentation
(CNPS)
Legal proof of health care provided: nursing
documentation is relied upon by the
courts as evidence of what was done or
not done when a patient sues.
5. 5
Purposes of Documentation in
Legal Proceedings
• To prove or disprove evidence of breach.
• To draw conclusions or make inferences.
• To prepare a statement of claim and
counterclaim.
• To use as evidence at trial.
• To provide to the experts for review and
analysis.
6. 6
The Medical Record
• Usually the focal point in litigation.
• The quality of the information in the
medical record can influence the
outcome of a legal action.
7. 7
Proof of the Standard of Care
Experts:
• Provide an opinion on the standard of
care and whether or not it was met and
caused harm.
• Provide an opinion on the adequacy of
the hospital policies, protocols,
procedures, guidelines.
8. 8
Expert Review
• Standard of Care [MD, RN].
• Causation (Did the breach or failure to
meet the standard cause the harm?)
[MD].
• Damages [OT/PT, CA, MD].
9. 9
CNO Documentation Standards
The nurse’s documentation provides a clear
picture of the needs or goals of the client,
the actions of the nurse, and the
outcomes.
10. 10
CNO Documentation Standards
• Clear, concise, comprehensive.
• Accurate, true, honest.
• Reflective of observations.
• Timely, chronological.
• A complete record of nursing care
provided, including assessments,
identification of health issues, a plan
of care, implementation, and
evaluation.
11. 11
CNO Documentation Standards
• Legible and non-erasable.
• Permanent, retrievable.
• Confidential.
• Client-focused.
• Completed using forms provided if
consistent with these standards.
12. 12
CNO Documentation Standards
• Document client preferences.
• Document the implementation of the care
plan.
• Document independent and collaborative
actions.
• Document information reported to
another provider and the provider’s
response.
13. 13
Documentation is Evidence
• The Plaintiff uses documentation to
prove that the standard of care was not
met [and harm was caused].
• The Defendant uses documentation to
prove that the standard of care was met
[or if not met, harm was not caused].
14. 14
The Legal Importance of Charting
• Recall of events over time is difficult.
• Timely, accurate records are essential in
establishing the quality of care provided.
• Discrepancies, inaccuracies will discredit.
15. 15
What Documents May Be Used?
• Full chart: mother and baby.
• Fetal monitor strips.
• Policies, protocols, procedures,
guidelines.
• Précis of meetings held with the family.
• Incident Reports. Personal Notes.
• Any document not protected by the Quality
of Care Information and Protection Act,
2004 (QCIPA).
16. 16
“Prudent Nurse”
• Current maternity textbooks.
• AWHONN: The Association of Women’s
Health, Obstetric and Neonatal Nursing.
• CNO: The College of Nurses of Ontario.
• SOGC: Society of Obstetricians and
Gynecologists of Canada
• Protocols, Procedures, Policies, and
Guidelines of the Hospital (if current).
17. 17
The Clinical Picture
Anyone reviewing the chart must be able to
see what transpired:
1. What happened
2. To whom
3. By whom
4. When
5. Why
6. The result of what happened.
18. 18
Sources of Nursing Liability
• Failure to perform assessments.
• Failure to recognize a change in patient
status.
• Failure to notify MD.
• Failure to follow policies and procedures.
• Failure to document.
• Failure to follow-up.
19. 19
The Hospital’s Responsibility
Public Hospitals Act: Public Interest: The
quality of care & treatment of patients.
• Ensure proper charting is completed.
• Ensure departments have reasonable
policies and clear standards of
acceptable practice.
20. 20
Hospital Insurance
• Healthcare Professional Liability Insurance
• Common claims involving nurses:
– Failure to monitor the patient
– Failure to document
• Scant notes
• Charting by exception and focus notes poorly
understood and inconsistently applied.
• Not reading other providers’ notes.
• Checklists used in place of progress notes.
22. References
• Canadian Nurses Protective Society. Quality Documentation. https://ben.cnps.ca/
• College of Nurses of Ontario, (2009). Practice Standard: Documentation, Revised
2008). Publication No.: 41001
http://www.cno.org/globalassets/docs/prac/41001_documentation.pdf
• Ontario Ministry of Health and Long Term Care (2015). Quality of Care Information
Protection Act, 2004. http://www.health.gov.on.ca/en/common/legislation/qcipa
• Society of Obstetricians and Gynecologists, (2007). Fetal health Surveillance:
antepartum and intrapartum Consensus Guideline.
http://sogc.org/guidelines/fetal-health-surveillance-antepartum-and-intrapartum-consensus-g
• Supreme Court of Canada. Joseph Brant Memorial Hospital v. Koziol, [1978] 1 S.C.R.
491, Date: 1977-05-17. Joseph Brant Memorial Hospital and Nurse G. Malette
(Plaintiffs) Appellants; and Katherine Koziol and Joseph Koziol, by Suggestion
(Defendants) Respondents; and Terrance L. Jeffries Respondent. 1977: February 23,
24; 1977: May 17. Present: Laskin C.J. and Martland, Judson, Ritchie, Spence,
Pigeon, Dickson, Beetz and de Grandpré JJ. On Appeal from the Court of Appeal for
Ontario.
Editor's Notes
Professional colleges
Litigation
Coroners’ Inquests
What are the legal implications of charting?
In the context of a nursing negligence lawsuit, nursing documentation has a two-fold purpose. Firstly, since the nursing notes provide a chronological record of the many events involving the
patient from the time of admission to the discharge date, they may be used to refresh your memory when you are required to give evidence, it is also common for the court to use nursing
documentation at trial to reconstruct events, establish times and dates, and resolve conflicts in testimony.
Secondly, your nurse’s notes may be entered as evidence at a trial to support your case. In this situation, your lawyer will rely heavily on your charting to establish that your nursing
process was “reasonable and prudent” in the circumstances and to show that your actions were not the cause of the patient’s injuries. Conversely, the patient’s lawyer will use the nursing documentation to try to show that your care failed to meet the standard of a reasonable prudent nurse.
What is the impact of not recording your nursing care?
The Supreme Court of Canada addressed this issue in the case of Kolesar v. Jefferies. in that case, a patient underwent a spinal fusion. Post-operatively, he was returned to a surgical unit and the next morning he was found dead. The chart was important in establishing liability in the Kolesar case because there were no nursing entries from 2200 hours until 0500 hours, when the patient died. The absence of nursing documentation allowed the court to infer that:
“nothing was charted because nothing was done”.
Charting omissions may work against you unless there is other credible evidence to demonstrate
that nursing care was indeed given. Nursing documentation is relied upon by the courts as
evidence of what was done or not done when a patient sues.
Omissions, later additions, inconsistencies, vague entries, errors, not chronological, not contemporaneous
Physicians and nurses are experts in the standard of care. Physicians can usually comment on the standards of care of nurses because of the team approach to obstetrical care – this is especially true in communication and areas of interface.
A physician expert, for example, a neonatologist or a specialist in maternal-fetal medicine, will provide an opinion with regards to causation. However, a nurse expert may say that the nurse’s failure to assess and document the blood pressure according to accepted standards, did not contribute to the outcome.
Damages are assessed over the expected life of the child. Loss of potential earnings, the costs associated with assistive devices, among other issues are considered by the court.
SBAR
Chart audits
Nurses are not the only providers with responsibilities in charting. The Public Hospitals Act states that hospitals have a responsibility for the quality of the care and treatment of patients, which includes documentation.
Involve nurses in the formulation of policies.
Keep all policies current and research-based.
To pay on behalf of the hospital all sums which the hospital is obligated to pay as damages because of bodily injury including death arising out of malpractice, error, or mistake.
Not covered, legal representation and attendance at the College and disciplinary hearings, inquests, human rights tribunals, and similar forums.
Nurses and other providers have professional obligations to chart and document appropriately, according to accepted standards.
The importance of charting in the health care context cannot be over-emphasized:
Communication
Continuity
Accountability
Legal ramifications is another reason to ensure that charting and documentation are appropriate and meet the standards expected.
