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LIKE ALL NURSES, you need to be aware of the potential for claims to be filed against you. Your best defense? Not just excellent practice but also excellent documentation. Keep the following guidelines in mind to make sure you're doing everything you can to avoid the possibility of a claim against you.
We've all heard the maxim, "If it wasn't documented, it wasn't done." But simply documenting something isn't enough; we must document it precisely and thoroughly. Otherwise, gaps in our charting leave us vulnerable to malpractice charges.
No "one-size-fits-all" note suits all patients. Using your experience and knowledge, tailor your notes to each individual, predicting possible complications and adverse outcomes and documenting with that patient in mind. For surgical patients, include notes about your assessment of postoperative complications; for obstetric patients, add notes on fetal and maternal complications; for head-injury patients, document your frequent neurologic assessments, and so on. Include normal as well as abnormal findings.
In a lawsuit, the timing of your findings can be crucial. When did you observe a patient first move her fingers after hand surgery? What did the fetal heart monitor indicate during contractions throughout the entire second stage of labor? If the patient has a neurologic disorder, what's his level of consciousness from one assessment to the next?
When you discover deviations from normal findings-the fingers are immobile, prolonged fetal heart decelerations are noted with delayed return to baseline, the Glasgow coma scale has decreased from 15 to 13-document what time you communicated this information and to whom. If you repeatedly report this information, your documentation must include this, along with whatever other efforts you made to bring your findings to the provider's attention.
When unusual incidents occur, make sure you notify the appropriate people, according to facility policy. For example, you should immediately advise your nurse-manager and risk management about any incidents that have liability potential. Keep an eye on forms: Complete all flow sheets or checklists, leaving no blanks; chart all given medications; and clearly mark discontinued medications or changed doses on the medication administration record.
Nursing entries such as, "MD aware," "nursing supervisor advised," and "visitor in room" don't help protect you. Which physician was aware? How can you prove you informed a provider when you can't identify her? What visitor was in the room? How can a witness be called to testify on your behalf when no one knows who he was? Always include at least the person's last name so he can be identified and contacted if needed.
Many plaintiffs' claims are based on the timing of events. The findings of what happened (or didn't happen), when, and in what order can determine the outcome of a case. When working in hospitals that have computerized charting, the technology helps confirm and preserve that information because the computer automatically stamps, dates, and inserts your "signature" into each entry. But in facilities that still keep paper records, you need to time and date every entry. That's because as charts are taken apart for copying, pages can get separated and mixed up. Be sure to use a complete date, including the year, and record time on a 24-hour clock or specify a.m. or p.m. Make sure that your watch is in sync with the hospital's clock and that you record the time accurately. Sign every entry using a complete signature, including your license (RN, LPN, and so on). If one entry is incomplete or broken by pages, sign it anyway and write "contd." Continue it at another point and refer to the incomplete note by writing "contd. from 6/7/04, 10:15 a.m." and sign that note as well.
Working in a unit that uses flow sheets that open into several pages? If so, make sure each page has the correct date on it.
Legible handwriting is important too. Sloppily written notes convey an impression-rightly or not-that your work is sloppy as well. You may save a few minutes by writing quickly, but do you really want to risk having your sloppily written notes misread? In particular, make sure your signature and status are legible so those who need you can find you easily.
As a travel nurse, you may be in a different location as often as every few weeks, so you'll be very dependent on a thorough orientation to each facility. Review the policies and procedures manual on day one-or before you start working, if that's possible-so you have a solid understanding of the facilities' practices. Look to your nurse-manager and other staff nurses to fill you in on current practices and keep your recruiter informed if you aren't getting the direction you need.
Without a doubt, understaffing can contribute to errors: The Joint Commission on Accreditation of Healthcare Organizations indicates that it's a factor in 24% of its sentinel event reporting. But understaffing is no excuse, legally or ethically, for substandard nursing practice. If you're working in an understaffed unit, be meticulous about your practice. Don't make exceptions because you're busy or you're working in an unfamiliar or short-staffed unit. If a patient is injured from a medication error that you made while taking a shortcut, no one will care about a nursing shortage. All that matters is that you departed from the standard of care and that your departure caused an injury.
So check ID bands when administering medications, avoid leaving medications at the bedside, observe the "five rights" (right patient, right medication, right dose, right route, and right time), document injection sites, label intravenous lines, and so on. That way, if you're involved in a lawsuit, you can say you followed the standard of practice for the profession. It means you did check the patient's ID band before giving him his medication, even if you'd been taking care of him for 4 days. You did so because it's part of your standard practice to do so, and you don't deviate from it.
The hallmark of nursing is patient advocacy. Our education encourages us to be critical thinkers who study beyond the "hows" and understand the "whys." We assess and analyze, rather than just following routines.
Make a conscious effort to keep your holistic hat on. If a patient was on a medication at home that hasn't been ordered with admission orders, ask if it should be continued in the hospital. Remember to check relevant lab values before giving medications. Push for psychiatric or social work consults if you think they're needed. Don't get so lost in what has to be done that you stop being a patient advocate.
Bashing lawyers may be "fashionable," but lawyers don't sue hospitals, providers, and nurses; patients do. Long before lawyers get involved, a provider/patient relationship exists, and the quality of that relationship plays a large role in the patient's decision to seek out an attorney.
You can shape your relationship with patients in a manner that protects you or in a manner than endangers you. From your own perspective, if someone causes you harm, whom are you more likely to sue? Someone you had a good relationship with, who made you feel she cared about you, and who treated you with dignity and respect? Or someone who was dismissive, took no personal interest in you, disregarded your privacy, and treated you coldly?
Patients remember nursing care more than any other hospital experience. Establishing and maintaining good relationships with your patients will go a long way toward creating goodwill.
Similarly, be careful not to criticize other providers in front of patients. If you have concerns, share them privately, away from the bedside. Although this may also sound like common sense, many plaintiffs have said that comments from one provider about another led them to sue.
A lawsuit that names you as a plaintiff or witness is stressful, but you'll survive. If you have good practice habits and documentation skills, you should be well protected.
Edith Ann Brous is a nurse-attorney, currently working at Piper Rudnick, LLP, New York, N.Y.
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