ORX Proceedings 2013_Layout 1 12/6/13 11:23 AM Page 54
How to Survive a Med Mal Suit
In court, the medical record is the care rendered.
S
loppy documentation is equal to sloppy care. As you learned in
nursing school, if it wasn't documented, it wasn't done, a point
Carmen Lester, RN, BSN, JD, CPHRM, and Jan Kleinhesselink, RN,
BSHM, CPHQ, of Lincoln (Neb.) Surgical Hospital repeatedly
drove home during their well-rehearsed presentation that was
more like a stage play. With great rhythm and precision, the nursing colleagues
and close friends walked and talked their audience through a real-life malpractice suit at their facility, from scary start to fortunate finish.
"In court, the medical record is the care rendered," they say. "Jurors view
good record keeping as an indicator of good care — poor documentation can
create an aura of poor care and damage the credibility of the healthcare
providers."
The details of the wrongful death case: A 39-year-old male patient, a married
father of 6, underwent a successful finger amputation at the surgical hospital in
n MEMORIES DIM, BUT THE RECORD REMAINS
On average, malpractice suits take place 3 to 7 years after the incident occurs, say Carmen Lester, RN, BSN, JD, CPHRM, and Jan
Kleinhesselink, RN, BSHM, CPHQ, of Lincoln (Neb.) Surgical
Hospital.
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S U P P L E M E N T T O O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E | D E C E M B E R 2013
