Defensive Documentation TIPS Series

Clinical staff in healthcare facilities have the burden of documenting everything they are doing on a daily basis as they care for their patients. This can be a daunting task in and of itself. Add to this the fact that, in the event of malpractice litigation, that documentation is going to be examined with a fine tooth comb by both the plaintiff attorney and the defense attorney and it may seem like an overwhelming task.

While it should not be overwhelming, it is a critical skill set for clinical staff to master, as documentation issues are a primary source of malpractice claims against nursing staff.

This blog series will highlight 3 defensive documentation tips in each each post for a series of posts.

1. Document Timely Vital Signs-Be absolutely sure you are following your company policy here. Do your post-op floors require hourly vitals for a period of time following surgery? If that is facility policy then clinical staff should be certain they have a set of vital signs recorded for each time period dictated by policy. Failure to follow facility policy gives a malpractice attorney a huge assist in proving negligence on the part of the clinical staff. Protect yourself. Protect your facility. Protect your patient.

2. Report and document changes in patient condition-This is huge for nurses. Every single time your patient has a deterioration in condition you MUST notify the provider AND document that you did so. Be certain you also document what the provider did and, even more importantly, did not do in response. "Phone call placed to Dr. XYZ to report increase in temperature, pain level and altered mental status. No new orders received." This may seem like you are throwing the provider under the bus but this is exactly how you protect yourself with your documentation. If you, as the nurse responsible for the patient, feel that the safety of your patient is at risk in a situation like this. that is when you activate your chain of command....then DOCUMENT that you did so!

Make sure when notifying providers of a change in patient condition that you relay the correct level of urgency and DOCUMENT exactly what you told the provider on the phone.

Real life example:

I recently consulted on a placental abruption case. Abruption happened in the middle of the night at a small hospital without 24 hour OB coverage. Fetal heart rate drops suddenly, uterine tone is suddenly lost...clear signs of abruption. The nurse calls the OB and this was the documentation: "Dr. XYZ called and asked to come for delivery." Does this convey the emergency to the doctor? Of course not. Is the doctor going to rush on over? Probably not. Make sure the urgency of the situation is not only conveyed to the doctor but is also documented as such.

3. Document patient behavior. Especially NONCOMPLAINT behavior. If the patient is refusing medications, document it. If the patient is getting out of bed without assistance, document it. Always remember that mitigation of damages can result from contributory negligence. If that patient who keeps getting up without assistance despite orders not to do so falls and breaks their hip BUT the nurse has documentation of 8 times in the past 24 hours where they found the patient getting up without assistance and stating they will get up when they want to then it will be very difficult to prove medical negligence that led to the patient fall.

More Defensive Documentation Tips in the next post!

If you would like to arrange for an in person defensive documentation course for your clinical staff or for your nursing

students use the contact link on this website and we will set up a time to talk.