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In a prior column, you discussed how to document a patient fall. The incident involved a nurse who discovered a patient who'd apparently fallen while trying to get out of bed, despite instructions not to get up without calling a nurse for help. I'm not clear about what information should be documented in the medical record versus an occurrence/event report, and why. Can you help?-S.D., VA.
In the nurse's notes, which are part of the patient's medical record, you'd document exactly what you saw and heard when you discovered the fall. Stick to facts only, not opinion or speculation. For example, you might write, "Discovered patient sitting on floor beside bed. Patient stated, 'I thought I could get out of bed by myself but I guess I'm still dizzy and I fell.'" Of course you'd also document your interventions, the patient's response to treatment, and all other information relevant to the patient's medical condition and care.
Note, however, that you wouldn't document "patient fell" unless you actually witnessed the fall. Your description of the scene and the patient's words speak for themselves. Coupled with prior documentation that the patient had been instructed not to get out of bed without help, this would provide excellent evidence of contributory negligence by the patient if the case went to court.
In contrast, the occurrence/event report is a risk management tool intended for internal use. It lets the risk manager evaluate reasons for the adverse event and take steps to prevent similar incidents in the future. Unlike the medical record, it's not usually subject to discovery in a lawsuit unless a defendant relies on it for evidence. (In that case, it would be available to the plaintiff too.) Because it's an internal document, it might contain information related to the incident that shouldn't appear in the medical record because it's not pertinent to the patient's condition (for example, that the unit was understaffed that day).
Bottom line, the patient's medical record is a discoverable document that can be used for or against you in court. Be very careful to use it to document only objective facts and findings pertaining to the patient's condition, nursing care, and medical treatment.
As charge nurse, I recently assigned a newly hired RN to insert an indwelling urinary catheter. Because this nurse had many years' experience in medical-surgical units, I expected her to manage this routine task easily. Apparently that was a mistake, because the patient experienced an adverse reaction related to the procedure and is threatening to take legal action. Who's liable here? Me, because I wasn't closely supervising her technique, or my employer, who hired her?-C.H., TENN.
Employers should follow standards in hiring new staff, but if a nurse being hired is licensed and has no known history of legal or work-related problems, it's difficult for an employer to know if the nurse is a safe practitioner or not. For your part, when you're assigned to supervise any other care provider, you have a duty to delegate appropriately or you can be held vicariously liable for any harm caused by that person. Appropriate delegation means ensuring that the care you're delegating isn't only within the person's scope of practice, but also appropriate for her level of expertise. As you learned the hard way, it's risky to assume a nurse is competent at a given task based simply on years of experience.
Before delegating to a new hire or a float nurse, ask questions regarding skill and experience level. Keep communications open and friendly so that those you're supervising will feel comfortable admitting what they can't do safely. If a nurse says she can't do a certain task, don't assign the task to her if it's a potentially risky procedure-either do it yourself or delegate to someone who can safely perform it. If it's not a high-risk procedure, demonstrate it for the nurse and then observe her doing it so she can learn to do it correctly. Document the supervision you provide so that you have a record of serving as a reasonable supervisor.
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