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Legal Aspect of Documentation

This document discusses the legal aspects of nursing documentation. It states that accurate documentation of patient assessments, plans, interventions and evaluations can help nurses avoid liability, while poor documentation could hurt a nurse's defense. It also outlines policies around maintaining patient confidentiality, ownership of medical records, and appropriate access to records. The document concludes with "dos and don'ts" of legal nursing documentation, such as the importance of recording normal findings, not altering records, and remembering that if an action is not documented, it cannot be proven that it occurred.

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3K views16 pages

Legal Aspect of Documentation

This document discusses the legal aspects of nursing documentation. It states that accurate documentation of patient assessments, plans, interventions and evaluations can help nurses avoid liability, while poor documentation could hurt a nurse's defense. It also outlines policies around maintaining patient confidentiality, ownership of medical records, and appropriate access to records. The document concludes with "dos and don'ts" of legal nursing documentation, such as the importance of recording normal findings, not altering records, and remembering that if an action is not documented, it cannot be proven that it occurred.

Uploaded by

abid
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Fundamental of Nursing

Legal aspect of documentation

• Documentation of patients' records, in the


nursing field as well as other health care
fields, is one of the most important aspects of
the profession
Legal aspect of documentation

• Each health care organization has policies


about recording and reporting client data, and
each nurse is accountable for practicing
according to these standards.
Legal aspect of documentation

• The nurse has a duty to maintain

confidentiality of all patient information”

• The client’s record is also protected legally as

a private record of the client’s care


Legal aspect of documentation
• Access to the record is restricted to health
professionals involved in giving care to the
client.
• The institution or agency is the rightful owner
of the client’s record.
• This does not, however, exclude the client’s
rights to the same records.
Legal aspect of documentation

• For purposes of education and research, most


agencies allow student and graduate health
professionals access to client records.
• The records are used in client conferences,
clinics, rounds, client studies, and written
papers.
Legal aspect of documentation
• Accurately documenting nursing assessments,
plans, interventions and evaluations is a
method of avoiding troublesome occurrences
and, possibly, a method of avoiding liability
after an incident has occurred.
• In contrast, a poorly kept record may not be
helpful and could hurt a nurse's defense.
Legal aspect of documentation
• When health care professionals are called as
witnesses in legal proceedings, they may
refresh their recollections of the facts and
circumstances of a particular case by
reviewing the medical record.
• During a legal proceeding the medical record
can be admitted into evidence
LEGAL DOs AND DON'Ts OF NURSING
DOCUMENTATION
• “If you did not write it down, you did not do it.
If you did not do it, you were negligent.” You
need not just to chart what you did but how
you did it.
LEGAL DOs AND DON'Ts OF NURSING
DOCUMENTATION
• Do chart your normal findings.

• This is especially important where the nurse is


monitoring a patient who is critically ill, where
things can change from good to bad on a
moment’s notice.
LEGAL DOs AND DON'Ts OF NURSING
DOCUMENTATION
• For example: “3:00 a.m., patient in bed
sleeping soundly.” What is the point of
charting that? Suppose the patient is found on
the floor at 3:05 a.m.?
• How long had the patient been there? How do
you prove that?
LEGAL DOs AND DON'Ts OF NURSING
DOCUMENTATION
• Don’t jump to conclusions. It is your job to
observe carefully. It is your job to chart data,
not conclusions.
• For example, a patient is found on the floor.
• Did the patient fall out of bed? Did the patient
fall trying to ambulate on his or her own
LEGAL DOs AND DON'Ts OF NURSING
DOCUMENTATION
• That is, if the patient fell out of bed you may
be liable but if the patient tried to ambulate
knowing he or she should not have you are
not going to be liable.
LEGAL DOs AND DON'Ts OF NURSING
DOCUMENTATION
• Don’t back-date your charting. As clever as
you think you are this is probably not going to
work.
• Don’t alter or destroy any charting. The legal
term for this is spoliation of the evidence.
• Don’t chart something about one patient in
another patient’s chart.
LEGAL DOs AND DON'Ts OF NURSING
DOCUMENTATION
• Don’t chart “I left a message.” Nurses have a
duty to advocate for the patient.

• If you do not hear from the doctor, you have


to call back, or call another doctor or ask your
supervisor what to do.
LEGAL DOs AND DON'Ts OF NURSING
DOCUMENTATION
• Do remember the Number One Rule, the
Golden Rule.

• It deserves repeating. If you did not write it


down, you did not do it. If you did not do it,
you were negligent.

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