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Don’t fail to document

Staff Development Weekly: Insight on Evidence-Based Practice in Education, April 9, 2008

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Understand that although documentation seems burdensome and not at the top of a busy day's priority list, it will be your salvation if the patient/family believes the care did not meet their expectations. This is especially true when a patient files or voices a complaint about his or her care or when there is an adverse medical event, such as a fall or medication error. A study published in the American Journal of Nursing analyzed 350 lawsuit case summaries, finding six major categories of negligence.

The lawsuits centered on nursing documentation that described negligent behavior in terms of "failure to, lack of, incomplete, ineffective, and improper." The six categories are failure to:

1. Follow standards of care
2. Use equipment in a responsible manner
3. Communicate
4. Document the patient's progress, response to treatment, injury, pertinent nursing assessment and physician orders
5. Assess and monitor
6. Act as a patient advocate

Editor's note: The above excerpt is from the online course "Nursing CE Series: Nursing Documentation - Reduce Your Risk of Liability." For more information on this and other courses, visit www.hcprofessor.com.

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