Article by Ryan King, Esq.
While nursing documentation plays an important role in patient care, it also plays a key role in medical negligence litigation. Documentation (or the lack thereof) can make or break a plaintiff’s case; and, even when a healthcare provider has met the requisite standard of care, challenging a plaintiff’s case in front of a sympathetic jury can be extremely difficult without documentation that contradicts the plaintiff’s allegations.
So, what does it take to effectively document a patient’s care from a litigation perspective?
The American Nursing Association’s (ANA) Principles for Nursing Documentation state that “[c]lear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practices.” Clear and accurate documentation promotes continuity of care and effective treatment, and it also facilitates care plans by allowing for effective communication between professionals both within the same office and in other facilities and disciplines.
It also helps to reduce liability risk both for individual professionals and for healthcare facilities.
Understanding the Role of Nursing Documentation in Medical Negligence Litigation
In medical negligence litigation, plaintiffs’ cases are often won or lost on the records. Factfinders view records as being more objective and unbiased than verbal testimony, and plaintiffs’ lawyers will use a lack of documentation as evidence of a lack of care. While these don’t necessarily go hand-in-hand, this is an easy link for sympathetic jurors to draw.
When it comes to the role of nursing documentation in medical negligence litigation, the basics go a long way. For example, here are some basic documentation practices that can help protect healthcare practitioners and facilities from liability:
- Always charting patient information after the patient receives care
- Charting patient information as soon aftercare as possible
- Writing neatly and legibly
- Using proper spelling, grammar, and medical terminology rather than shorthand
- Promptly scanning handwritten notes and adding them to patients’ electronic files
- Signing and dating every entry
- Avoiding block charting and using drop-down menus only when they provide an accurate and complete record
- Filling in all blanks (even if this means writing “N/A”)
- Including only objective information in patients’ files
- Never criticizing the facility in patients’ documentation (for example., stating that “care could not be given because the floor is understaffed”)
When nurses write notes, clarity is key as well. For example, all notes should clearly identify the patient to whom they relate, and nurses should specify whether their notes reflect a patient’s subjective complaints or a practitioner’s objective observations.
While charting is often viewed as “getting in the way” of patient care, especially on busy floors, the reality is that charting and patient care are intertwined. Charting is a necessary part of the process—and, with the right systems in place, it doesn’t have to be overly burdensome, time-consuming, or overwhelming.
Finally, it is also important to keep in mind that nursing documentation can be a double-edged sword. If a patient’s chart is sloppy or incomplete, or if it shows that the patient’s care was inadequate, then the patient’s lawyer will be able to use this to the patient’s advantage. As a result, when implementing nursing documentation policies, it is imperative that healthcare providers take a comprehensive approach focused on both positive patient outcomes and positive outcomes in litigation.