Documentation, part 1: Principles for self-protection. Preserve the medical record--and defend yourself.
This article discusses principles that inform all good methods of charting and examines an actual court case to illustrate how adequate documentation can protect nurses against allegations of negligence and malpractice. Also discussed are the importance of preserving the medical record and mistakes commonly made in charting that leave nurses vulnerable to lawsuits.
Monarch
Kammie
K
Sigma Theta Tau International, USA. kammie@stti.iupui.edu
D004282:Documentation; D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008499:Medical Records / Q000331:legislation & jurisprudence / Q000592:standards; D009737:Nursing Records / Q000331:legislation & jurisprudence / Q000592:standards; D012308:Risk Management; D014481:United States