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MEDICAL MALPRACTICE
Deficiencies in documentation
There are 8 common charting errors that can compromise a
liability defense:
• failing to record pertinent health information;
• failing to record nursing actions;
• failing to correctly record medications;
• recording on the wrong chart;
• failing to document patient treatments;
• failing to record changes in condition;
• transcribing orders incorrectly; and
• writing illegibly.
POP QUIZ
3 Suit-Related True-or-False Scenarios
The answers to these true-or-false questions might
surprise you.
• If it wasn't charted, it wasn't done. / False. In nursing
school, we learned the age-old adage, "If it wasn't
documented, it wasn't done." Although this is sound
advice, and we healthcare providers should strive to
document as much as possible, smart lawyers can
successfully defend cases with less-than-perfect
documentation by drawing inferences using other
indicators.
• Information shared in the post-op report is admissible
as evidence in a case. / True. Communications among
care providers during the post-op report, or even at
change of shift, are admissible in a case.
• Personal notes kept at a nurse's home are admissible as evidence in a case. /
True. Facilities should educate staff on raising concerns with supervisors rather
than keeping notes at home.
— Jan Kleinhesselink, RN, BSHM, and Carmen Lester, RN, JD
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