Legal Implications of Documentation

Remember that the medical record is a legal document. It must be factual and accurate. You do not want to include your personal opinions. You want to be precise, concise, clear, and comprehensive. You may record your observations but not your interpretations. You may also quote the patient, but be careful not to use something out of context. Always follow these tips, and your documentation will be an asset to the care you provide:

  • Be accurate and honest.

  • Document in a timely manner — only during or after providing the care.

  • Provide complete information regarding assessment, nursing diagnosis, nursing interventions and the plan of care, and evaluation of outcomes.

  • Be sure it is legible and in permanent ink.

  • Be sure all information needed for any forms used is complete and accurate.

  • Never chart ahead of time. This is a trap that many nurses fall into particularly when the nurses use blocks of time to document so that a statement could cover two hours at a time. This happens on the night shift frequently when nurses document, for instance, that the patient “is sleeping comfortably” from 10 P.M. to 7 A.M. The patient slept through the night with no complaints and there was no reason to awaken them. So they lump together two-hour blocks and just repeat over and over that the patient was sleeping comfortably.

    Well, that may be fine, except that Mrs. Kellerman got up at about 6:32 A.M. and went to the bathroom. Her nurse had just checked on her five minutes before and had gone to complete her charting and to give report. Mrs. Kellerman arrested on the toilet at about 6:35 A.M. but her nurse documented that she was still in bed sleeping comfortably at 7:00 A.M. By the time they found her at 7:20 A.M., she could not be resuscitated, and the M.D. cancelled the code.

    Had the nurse accurately recorded that she had checked on Mrs. Kellerman at 6:25 A.M. and indeed she was still in bed at that time, there would not have been an issue raised. However, when the chart said that she was still asleep in bed at 7:00 A.M., the family got a little curious why so little effort was made to attempt resuscitation efforts and why they failed.

    Don't document something until you have actually done it and when you document it, be accurate in your time frames. Erroneous documentation can have the same ramifications as other errors.

    Don't chart medications before you give them either. You could be on your way to administer a medication and get flagged down to help catch a patient who's falling out of bed. In all the resulting commotion, you forget to deliver the medication, but you already documented that you've given it. An hour and a half later the patient is really in pain and wondering what's taking so long with his pain medication. He asks his night nurse and when she checks the chart it shows he recently had a dose. She tells him, “It's not time yet.” He's perplexed, but suffers through it. It isn't until days later when you're doing laundry that the medication cup falls out of one of your uniforms. By now you don't even remember whose it was and assume he got one when he asked again.

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