Documentation & litigation.
What you see on "CSI" or "Law and order" may give you the idea that medical malpractice attorneys routinely use DNA, voice print analysis, and high-tech laboratory assays to prosecute or defend lawsuits. For the most part, this is not the case. With the exception of whatever witness testimony may be available, the only evidence in a malpractice case is the medical record. The patient's chart is used to demonstrate accreditation and regulatory compliance, and to make reimbursement determinations. It also is examined by licensing boards in deciding disciplinary action. For these reasons, it is imperative that nurses consistently use acceptable documentation practices.
Brous
Edie
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D004282:Documentation; D005568:Forms and Records Control; D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008499:Medical Records; D014481:United States