1. Comprehension: Nursing documentation is often the key to understanding the events that spawn a nursing or medical malpractice claim. The medical record can refute or support the plaintiff’s or defendant’s version of events.
2. Screen cases: Careful scrutiny of the medical record can eliminate many potential suits and lead to early settlements of claims that have merit. Nursing documentation often paints a vivid picture for both the plaintiff and defense attorneys, with each side using the record to draw conclusions about the events of the case. Expert witnesses will rely on the charting to form opinions about adherence to or deviations from the standard of care. It is therefore essential that the attorney have an intimate understanding of the medical record and how nurses document.
3. Treatment and damages: Nursing documentation provides essential information that describes a patient’s injuries or health status, major problems, effectiveness of treatment, and cooperation or lack of compliance with treatment. When correlated with other parts of the medical record, nursing documentation usually provides a complete picture of the patient’s condition. Discrepancies, if any, between the nursing documentation and that of other healthcare providers, can be crucial in a particular case. Nurses notes pinpoint delays in care and improvement or worsening of symptoms. Timing may be a critical factor in delivery of care. Physicians rarely time their notes, nurses usually do.
4. Legibility: Nursing documentation is often the most legible part of the chart and contains information that must be considered when evaluating a personal injury, malpractice, or product liability case. Comments that patients make about their injuries or the details of a personal injury case are often recorded verbatim by nurses. For this reason the attorney should request a complete medical record in order to gather facts that bear on the patient’s injuries.
Examples of gold
- that prior back injury from another car accident the plaintiff did not describe to his attorney,
- the note written in the recovery room about the time the burn was first seen on the patient’s leg,
- the emergency room note that the patient had AOB (alcohol on breath),
- the nursing note that an anonymous caller reported the father of a child with suspected shaken baby injuries had a history of hitting his wife,
- the note in the records about a loving son: He stated “I’ll be honest with you, I wouldn’t care if today she fell and split her head open. Then she’d have to go to the hospital and they could take care of her so I can do the things that I have to deal with.” (Thanks to Tom Conlon Esq. for this note) and
- the medication administration record that showed the patient received Morphine before the drug screen was done.
Yes, these are all true examples. Don’t be surprised by information in the medical records that could harm your client. Can’t read or are too busy to read the nurses’ notes? Retaining Med League’s legal nurse consultants to do a medical record summary or chronology can uncover important information that affects your case.
This blog post is modified from Nursing Documentation, a chapter written by Pat Iyer and Sharon Koob, in the fourth edition of Nursing Malpractice. See our webstore for details.