Nurse documentation: not done or worse, done the wrong way--Part II.
OBJECTIVE
To focus on nursing documentation and how it can lead to a malpractice lawsuit.


METHODS
Nursing, non-nursing healthcare and legal journals, case law, and related Internet sources.


RESULTS
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.


CONCLUSIONS
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.
Frank-Stromborg
M
M
School of Nursing, Northern Illinois University, DeKalb, USA.
Christensen
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D003142:Communication; D003219:Confidentiality; D004282:Documentation / Q000592:standards*; D006801:Humans; D008318:Malpractice; D008508:Medication Errors; D009737:Nursing Records / Q000592:standards*; D009859:Oncology Nursing; D059408:Pain Management; D013689:Telephone; D014481:United States