Whether you're an attorney navigating personal injury and medical malpractice cases or a legal professional facing challenges with nursing records, this article provides crucial insights into the role nursing documentation plays in legal cases—and how you can leverage it to your advantage.

In personal injury and medical malpractice cases, nursing documentation serves as a critical piece of evidence. Here’s a breakdown of what attorneys need to know when dealing with nursing documentation in such cases.

1. Accurate and Timely Documentation

Nursing records are designed to offer a clear and concise real-time account of patient care.

Key Tip for Attorneys:

·        Look for delayed or missing entries, as they may indicate attempts to conceal errors or may lead to inaccurate reconstructions of the patient's care timeline.

2. Completeness and Clarity Are Non-Negotiable

Complete documentation includes every action taken by healthcare providers, including assessments, treatments, medications administered, and patient responses.

Key Tip for Attorneys:

·        Look for unclear or incomplete records

·        Look for vagueness in documentation

·        Look for missing or inconsistent nursing care plans

3. Alterations and Amendments

One major legal pitfall in nursing documentation is improper alterations. While it’s permissible to amend a patient’s medical record, these changes must be clearly indicated with a time stamp, date, and reason for the amendment.

Key Tip for Attorneys:

·        Look for unauthorized or hidden alterations

·        Look for any edits or late entries

·        Look for consistency and legitimacy

4. Adherence to Facility Protocols

Nurses must follow specific documentation protocols established by their healthcare facility. These protocols dictate how frequently assessments should be recorded, how to chart specific events, and what to include in the documentation.

Key Tip for Attorneys:

·        Request the facility’s internal documentation protocols

·        Look for compliance with national standards of nursing care and practice

5. Electronic Health Records (EHR) and Audit Trails

Electronic Health Records (EHR), guarantee that every modification, access, or entry is timestamped and traceable. Metadata within the EHR can “expose alterations made to an EHR days, weeks months, or years after the patient encounter” (Legal Nurse Consulting Principles and Practice 4th edition).

Key Tip for Attorneys:

·        Request access to EHR audit trails in complete Excel spreadsheet format

·        Review the audit trail in conjunction with the medical record

·        Check and scrutinize copy paste entries

6. Charting by Exception

Many healthcare facilities adopt "charting by exception,"  nurses document only abnormal findings. This can result in crucial patient care details being omitted from the record.

Key Tip for Attorneys:

·        Know the charting method of the healthcare facility

·        Be thorough in questioning whether the absence of documentation reflects the true status of patient care.

·        Avoid the assumption of normalcy

·        Look for inconsistencies in the documentation

7. Take Action: Partner with UPvision Consulting Today

Don’t let medical-legal challenges regarding nursing documentation overwhelm you. Partner with UPvision Consulting and gain the clarity and support you need.

Reach out to UPvision Consulting now to get started on bridging the gap between medicine and law with confidence and clarity. Visit our contact us page or call us directly to schedule your consultation!

American Nurses Association Documentation Standards https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf