title: The clinical record: recognizing its value in litigation.
abstract: Documenting completely and accurately is standard nursing practice, yet many nurses do not seem to understand that proper documentation is crucial to the communication and critical decision-making necessary to meet patients' needs. In fact, failure to document can have lethal consequences. Documentation of intake and output (I & O) is used here as an example of the evidence attorneys and nurse experts look for in the clinical record of elders. From exhibits of I & O records, juries can determine if nurses collected sufficient data for appropriate decision-making to protect the patient from harm. Readers are invited to test themselves to determine if their own I & O documentation meets acceptable standards of nursing practice. If readers find areas for improvement, self-study or group in-services can be held to improve the documentation and use of these data.
authors.forename: Dolores Marsh
authors.initials: DM
authors.lastname: Alford
mesh_terms: D019985:Benchmarking / Q000331:legislation & jurisprudence; D004282:Documentation / Q000592:standards*; D005104:Expert Testimony / Q000331:legislation & jurisprudence; D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence*; D009737:Nursing Records / Q000331:legislation & jurisprudence*; D014481:United States