Missing Nursing Documentation

“If you didn’t chart it you didn’t do it.” In the medical legal world, this expression engenders more fear in nurses than almost any other phrase as it is used to reiterate the importance of documentation. The phrase is also used to accuse nurses whose documentation is not complete.

Incomplete documentation can dramatically affect a malpractice case. In the ideal world, all pertinent observations and interventions are recorded. But is “If you didn’t chart it you didn’t do it” true? For a variety of reasons, medical records may be incomplete. Emergency situations, such as cardiac arrests, often result in gaps in documentation as patient needs take priority.

Ideally, the nurse tries to record detailed notes after the emergency is over, but this does not always happen because the nurse must direct attention to the other patients who took a back seat to the crisis. Sketchy documentation complicates the defense of a case and provides the plaintiff’s attorney with an opportunity to advance theories of liability.

Plaintiff’s attorneys may use the phrase, “If you didn’t chart it, you didn’t do it” to convince the jury that essential care was not given. Defense attorneys sometimes attempt to preempt the anticipated attack on the nurse’s credibility or documentation. This can be brought up on direct examination of the nurse during the trial by having the nurse testify about the impossibility of recording every detail or observation of the patient. Another useful technique is to have the nurse testify about the nurse’s usual practice which may or may not be recorded in the medical record.

Missing documentation coupled with a poor outcome complicates the defense of cases no matter what strategy is employed, and it provides the plaintiff with an opportunity to successfully argue that care was not rendered. In the case below, the nurses could not prove they contacted the physician if they did.

The plaintiff, age sixty-three, suffered a back injury and could not to return to work as a nurse. She decided to have an anterior approach lumbar fusion of the spine. This was to include surgery to the spine from the front of the body and then a day or two later, surgery from the back.

For the anterior approach, the plaintiff’s abdomen was opened, and her internal organs were moved in order to get to the spine. After surgery, the plaintiff had fluctuating blood pressure and no pulse in the left leg. The nurses noted the lack of pulse in the leg but did nothing about it.

The next morning, when Dr. Brown arrived to perform the second part of the surgery, he discovered her problems and had her rushed for a CT scan which showed internal bleeding in her abdomen and a block¬age of the artery which supplies blood to the left leg. The plaintiff was transferred to another hospital by helicopter, but the surgeons there were unsuccessful in salvaging the leg and an above-knee amputation was performed.

The plaintiff had been unaware of the problem with the leg overnight due to being heavily medicated. The plaintiff’s abdomen took four years to heal because the surgical incision wouldn’t fully close due to the swelling of her organs and the internal bleeding. The plaintiff also had infections and required repeated surgeries to repair the damage to her abdomen. The matter settled for $5.25 million. 1.

Good documentation is consistent, concise, chronological, continuing, and reasonable complete. 2.

Cites:
1. Laska, L. (Ed), “Woman suffers lack of pulse in leg after spinal surgery”, Medical Malpractice Verdicts, Settlements, and Experts, January 2010, page 37
2. Legal issues in the care of pressure ulcer patients: Key concepts for healthcare providers, International Expert Wound Care Advisory Panel, 6/22/2009

This blog post was modified from  “Nursing Documentation”, in Nursing Malpractice, 4th edition, 2011, available here.

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