Documentation, part 2: The best evidence of care. Complete and accurate charting can be crucial to exonerating nurses in civil lawsuits.
Properly documenting care in a patient's medical records is essential and, in the event of a lawsuit, provides evidence that the care that was provided met professional standards. Even nurses who meet the standards of care must document that care fully and accurately to avoid being vulnerable to accusations of malpractice that may result in costly jury verdicts and court decisions.
Ferrell
Kathy Graves
KG
Thompson's Station, TN, USA. kathy@ferrellconsulting.com
D000368:Aged; D001026:Coronary Artery Bypass / Q000451:nursing; D004282:Documentation; D004750:Enteral Nutrition / Q000451:nursing; D006801:Humans; D008297:Male; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008499:Medical Records / Q000331:legislation & jurisprudence*; D009737:Nursing Records / Q000331:legislation & jurisprudence*; D011785:Quality Assurance, Health Care / Q000331:legislation & jurisprudence / Q000592:standards*; D014481:United States