SAN ANTONIONinety-nine percent of the people you treat
are not going to sue you, Marilyn Frank-Stromborg, EdD, JD,
said at the Oncology Nursing Societys 25th Annual Congress. But
for that small percentage of cases where there are going to be
problems, you must know how to protect yourself and your institution,
she said, and that begins with the practice of defensive documentation.
This type of documentation is akin to the practice of defensive
medicine that physicians have been practicing for years by
ordering a variety of tests to cover all possible scenarios.
Defensive documentation consists of accurate and complete patient
charting, said Dr. Frank-Stromborg, chair and professor, School of
Nursing, Northern Illinois University, DeKalb.
This includes documentation of the patients history, physical
changes, medications, treatments, chemotherapy administration, side
effects, any complications encountered, family concerns, and all
The patient record not only serves as the confidential record
of all the care that was provided, but it is a business and a legal
document, Dr. Frank-Stromborg said. The patient record is the
first piece of evidence that will be looked at when professional
negligence is alleged.
When a person commits a negligent act in his or her professional
capacity that results in an injury, it is called malpractice,
Dr. Frank-Stromborg said.
In any medical malpractice suit brought against a nurse, the patient
must prove the following: that the nurse owed a duty of care to that
patient, that the nurse breached the duty with conduct that violated
the standard of care recognized in the profession, and lastly that
the patient suffered damages as a result.
The patient must prove that the breach of duty was the cause of the
suffering. We call that the but for, Dr. Frank-Stromborg
said. But for what you did, the patient would have
There are several situations in a medical record that can raise a red
flag for the attorney trying the case, Dr. Frank-Stromborg said. Time
gaps or improbable events are two of these. Remember, it is
your peers reading the medical records. They read your notes, and
they know what is probable and improbable, she said.
The omission of key facts, the omission of safety interventions, and
limited nursing assessments are also problematic. If you have a
seasoned clinician reading your notes, that person knows how many
assessments you should be making, Dr. Frank-Stromborg said.
Altered records, unsigned chart entries, and sloppy, incomplete
records will also alert the patients attorney to a potential
problem. Alteration of records can be very serious, and in some
states nurses who do so may have their license revoked.
Risk Reduction Strategies
There are several strategies that can be employed to reduce the
chances of a lawsuit, Dr. Frank-Stromborg said. One of the most
important of these is to maintain a legible record that can be
deciphered by all individuals who need to review the chart.
Records must not be ambiguous, she cautioned. Whether or not good
medical care was provided, lawyers can always use an ambiguous chart
entry to their advantage. Even if a practice is standard, it must be
placed in the record. The presumption in the law is that if it
is not documented, it was not done, she said.
Conversations must also be recorded, particularly instructions to the
patient and referrals. The failure to correctly document vital
information that would be used by other health care providers in
rendering treatment can result in a malpractice action.
Information entered into a patients record must be checked. A
medical record that is considered complete and thorough may still be
considered inaccurate documentation if it contains erroneous
And just when you thought you couldnt handle any more
responsibility, nurses should also do what is necessary to ensure
that other members of the health care team meet their respective
responsibilities for charting, Dr. Frank-Stromborg said.
If errors are made, they must be reported. Nurses have an
ethical and a professional obligation to report their own
errors, she said. As more and more attention is given to
the high incidence of medication errors, you may start seeing federal
legislation mandating that health care professionals report their
mistakes or suffer having criminal charges levied against them.
There are several simple rules to follow to ensure the record is
complete and accurate, she said. These include writing in the correct
chart, making entries in order of consecutive shifts and dates, and
writing the complete date and time of each entry.
Concise, factual, concrete, and specific terminology must be used.
However, Dr. Frank-Stromborg said, you want to use the
patients words in describing symptoms, so you should get
comfortable using quotes.
Acceptable hospital abbreviations may be used, but she advised
against use of other types of abbreviations.
Charting should be done in ink, and each entry should be signed with
the nurses name and title, with no space between the end of the
charting and the name.
There are also several charting behavior habits that must be avoided,
Dr. Frank-Stromborg said. These include charting in advance. I
have actually seen charts where people wrote patient tolerated
procedure well only to have the patient bleed out during the
procedure, and then you are in the position of having to defend how
and why you charted in advance.
Nurses should avoid relative statements such as wound is
healing, she said. Measure it. Talk about the dressing.
Talk about the smell. Talk about the color.