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Archive December 2020 XXI, No. 12

Medical Malpractice: Documentation is Never an Afterthought

Real-time records present the facts if a case ends up in a courtroom.

William Duffy

William Duffy, RN, MJ, CNOR, FAAN


DULY NOTED Recording the steps you took to provide good patient care in an electronic health record can make all the difference in a lawsuit.

You do countless things over the course of a case to ensure a successful outcome, but often don't think to include them in the patient's chart because, well, they seem like routine tasks. That's fine — until there's a problem. If complications occur or mistakes happen and your facility gets sued, clear and accurate charting could help you avoid legal trouble. Here are five ways to ensure documenting is always completed and done properly.

1Respect the process
You're constantly under the gun to complete cases, turn over the room and get the next case started. Completing the patient's chart might not seem like a priority, especially if the procedure was routine and you performed tasks you've done thousands of times before. But there's a reason why we chart. It's to tell the story about the reasonable care provided to the patient. While it might seem like the least important and most tedious task before you at the moment, it truly is your best weapon for defense against malpractice claims.

Juries believe that people will lie and embellish their stories to make themselves look better. They don't, however, question documents that were written at the time of the care before the lawsuit was filed. They view it as the real story you wrote down at a time when there was no reason for you to lie. It's best to always make note of your good work.

2Don't cut corners
Resist the urge to pre-chart, even if you know you'll be busy later, you know what the surgery is going to be like and you want to save a couple minutes by documenting ahead of time that something was done. This is a less hazardous practice with paper charts, because no one knows when notes are written, but every entry in electronic medical records is time-stamped. Don't put yourself in a position of having to explain to a jury how you noted at 7 a.m. that the patient came out of their surgery with no pressure injuries when in fact the procedure didn't begin until 7:15 am. Even if that aspect of the case doesn't have anything to do with why the patient is suing, inconsistencies in charting will put all the testimony from your side into question.

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