Nurse Documentation: Not Done or Worse, Done the Wrong Way—Part II

Purpose/Objectives: To focus on nursing documentation and how it can lead to a malpractice lawsuit.

Data Sources: Nursing, non-nursing healthcare and legal journals, case law, and related Internet sources.

Data Synthesis: To avoid liability for inadequate or inaccurate documentation, nurses must be aware of how their documentation can either lead to a malpractice claim or actually decrease their chances of ever being named in a malpractice lawsuit. Malpractice cases often are decided based on documentation. The only viable way to defend against allegations of professional negligence is accurate and complete patient charting or defensive documentation.

Conclusions: By examining case law involving inadequate or inaccurate documentation, nurses will be able to effectively adopt documentation practices or policies to decrease potential litigation.

Implications for Nursing Practice: Educating nurses about the principles of documentation and the importance of implementing risk-reduction practices will help guard against liability and ultimately improve patient care.