Most nurses have heard the phrase “if it is not documented, it is not done”. The reality is, this is not a true statement and a nurse may have very well provided care that was not documented. Not documenting the care we provide is careless and not living up to our responsibilities as an accountable nurse. On the other hand if it is done and not documented it can also be considered an omission, for example, an error in the care we provided. Not documenting properly according to our standards of care as nurses opens us up to liability for negligence and malpractice.
Negligence is defined according to Peterson & Kopishke (2010) as a failure to act as an ordinary prudent person would under similar circumstances (p. 7). Negligence requires proof of four elements. These are: “A duty”, a breach of that duty, “proximal cause” in which there is a connection between the breach of duty and the harm to the patient, and “damages or injuries” suffered (p.7). Professional negligence is not ordinary as the professional, such as the licensed nurse is held to standards of professional practice” (p.7). Standards of care determine or communicate the “reasonable conduct” and responsibility of the professional (p.7).
Malpractice according to Peterson & Kopishke (2010) is “misconduct, negligence, or failure to properly perform duties according to professional standards of care” (p.579). According to PersonalInjuryPlace.com the definition of Nursing Malpractice is “negligent or intentional actions by a nurse which causes injury or loss to a patient” https://www.personalinjuryplace.com/glossary/nursing-malpractice.
It is important to know and understand the laws and standards in the State in which we practice our nursing. In regard to documentation, failure to document in compliance with these standards can cause harm whether the failure to comply was intentional or not intentional. As a professional licensed nurse we have the duty and responsibility to perform documentation of the care we provide according to our communicated standards of care.
As an Assistant Professor of Nursing I teach students how to organize and document in the medical record. As a Legal Nurse Consultant one of my responsibilities is to understand how to organize records in a chronological order, interpret, and analyze the document data. I have come to understand that assuring that proper documentation standards are met in our practice settings can at times be challenging. Regardless of these challenges nurses must assure the following in their legal documentation (Taylor et. al. 2011):
- Errors if handwritten are crossed out with one line, initialed, noted with the word error
- Assure clarity and conciseness
Following the nursing process is also of great importance. The nursing process is our fundamental tool for problem-solving and decision making in our practice. Assure in nursing documentation and care to include and follow NANDA standards (Ackley & Ladwig, 2015) (Taylor et. al. 2011):
Also, there are many other things to assure we document. These include but are not limited to (Taylor et. al 2011):
- Any change in patient condition
- Any provider notifications and orders
- Any treatments the patient has undergone
- Any medications administered
- Refusal of any medications or treatments and care
- Any interventions in care
- Patient responses to the care provided and treatments performed
- Any concerns or complaints voiced by the patient and/or family
There is also a list of what not to do in a legal medical record. All items on this list I have directly observed of others in my practice as a challenge for some. Keep in mind as you read through these, that as professionals we must never cover up errors in the medical record or alter the record in any way. This is not an all-inclusive list (Lockwood, 2017-2019, RN.org).
- Never use white out to make corrections
- Do not abbreviate (even when using approved abbreviations clarity can be an issue)
- Never chart in the future. If it is not done yet we cannot say it has been done.
- Do not use subjective terms. Unless it is the patients exact words in quotation marks.
- Never engage in work around’s when documentation systems are not working properly or when they are cumbersome or you are in a hurry
- Never delete entries
- Never alter documentation entered by another professional
I mentioned above that I have come to understand the challenges of completing this responsibility in our clinical care settings. Although the advancement of technology has presented us with potential for reduced risk and improved efficiencies it has not eliminated the risk of failure to document or failure to document appropriately. Only the nurse who documents can assure that his or her documentation meets the standard of care. If you are in an organization or a setting where documentation is difficult to complete according to the standards of care, as a professional nurse you hold the responsibility to advocate for an improved environment. Nursing management and the organization also have the responsibility to assure that documentation is able to be achieved according to professional nursing standards. Here is a non-inclusive list of actions that can be taken to assist in assuring your nursing environment is documentation safe:
- Require and perform nursing documentation education
- Perform routine medical record reviews to assess for documentation errors
- Hold regular documentation quality meetings where these review findings are reported and discussed
- Assure that your nurse to patient ratios and acuity are supportive of safe nursing practice
- Know your standards for nursing practice and documentation and follow them
- Assure your documentation tools are not only meeting regulation standards but are also designed for the needs of your patients, organization and nursing staff
- Hire a third party such as a legal nurse consultant to assist you in examining your documentation practices, providing education, development of policies, and more.
Assuring proper documentation of all patient care should not be a burden in our nursing practice. This responsibility is of priority importance in the communication between the patient care team. Without excellent nursing documentation the care other professionals such as physicians, practitioners, therapists and more may not be appropriate for the needs of the patient involved (https://www.americannursetoday.com/protecting-yourself-from-malpractice-claims/). As a key professional on the care team, the nurse’s documentation serves as the conduit for excellence in patient care and outcomes.
I hope you have enjoyed this week’s Talk Tuesday and have found at least one take away to apply in your practice today. Before you leave my site please take time to enter your email and follow my weekly blog.
The Legal Nurse
Ackley, B. J., Ladwig, G.B,, (2015). Nursing diagnosis handbook: An evidence-based guide to planning car. 11th ed. St. Louis, MO: Elsevier ISBN 978-0-323-39020-0
Lockwood, W. (2017-2019). Documentation: Accurate and Legal. Continuing Education. RN.org. Retrieved at: http://www.rn.org/courses/coursematerial-66.pdf
Peterson, A. M. & Kopishke, L. (2010) Legal Nurse Consulting Practices. 3rd ed. Boca Ranton, FL: CRC Press ISBN 978-1-4200-8948-6
Peterson, A. M. & Kopishke, L. (2010) Legal Nurse Consulting Principles. 3rd ed. Boca Ranton, FL: CRC Press ISBN 978-1-4200-8951-6
Taylor, C., Lillis, C. & Lynn, P. L. (2011). Fundamentals of Nursing: The art science of nursing care. 8th ed. Philadelphia, PA: Lippincott-Williams & Wilkins ISBN: 978-1-4511-8561-4