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I work at the bedside in a telemetry unit where the patient/nurseratio is 5:1. How should a reasonable and prudent nurse format nursing notes after the shift has ended to minimize liability?-G.L., ILL.
Timeliness is a key principle of safe documentation, so rule one is this: Don't wait until the shift ends to document your nursing care. The medical record should reflect the continuity and timeliness of care for each patient. Sometimes you can't help making a late entry, but delaying it until hours later could affect accuracy. And because the entire health care team relies on the medical record as a communication tool, other care providers may provide inappropriate care if the documented information isn't current.
Your documentation should reflect your role as the patient's nurse. As soon as possible, document your assessments, interventions, and evaluation of those interventions. Include any significant statements the patient made and any changes in his clinical status. Indicate when and how you notified the primary care practitioner of those changes, exactly what you told her, when and how she responded, and the patient's status after implementation of any new orders.
Timely, factual, completed, and accurate documentation is essential to protect your patient and yourself. Courts still believe that "if it wasn't documented, it wasn't done," and finding evidence of care that wasn't documented can be very difficult if you're involved in a lawsuit.
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