Nurse carrying file folders with documents inside

I Have Been Subpoenaed: Now What?

The year is 2020 and you are sitting waiting for your turn to testify in a wrongful death trial against your employer. This lawsuit has been brought by the family of a patient you took care of for 8 hours, 2 years ago. If your documentation is complete and factual, and you have followed policy and procedure you should be a great witness.

The most important role of the medical record is to assure that the high-quality patient care you provide is documented in a clear and concise manner.

These principles are not new and lapses in applying these principles may create complications when documentation is presented as evidence to defend against allegations of malpractice, negligence, or failure to meet standards of care.

By concentrating on the principles of documentation your documentation will reflect the quality care you provide and reduce the risks of a lawsuit.

One of the cardinal principles of legally defensible documentation is adherence to organizational policy and procedures (P&P), standards of care, guidelines, competencies, and any other organizational document that guides the care of patients. The reasons for deviation from these documents must be clearly supported in the medical record.

Consider this:
Your assignment included a patient who was admitted for a routine surgical procedure. He was alert, oriented, and capable of self-care. You cared for him only briefly and provided pre-operative teaching. He never returned to your unit. He went from the operating room to PACU to ICU where he died.

Now, 2 years later in court, you must recall the details of the care you provided on the pre-operative evening when you had 5 other pre-operative patients. The only reference you will have to assist you is your documentation of the events of that evening. If the documentation is vague, judgmental, inaccurate, incomplete, or untimely, it will not assist you in substantiating that you met standards of care. In fact, your documentation may be a witness for the plaintiff.

Did you know that when caring for neonates or pediatric patients, that litigation may occur up to their 21st birthday? Can you remember what happened two weeks ago? Imagine having to recall your patient care 21 years later. Only good documentation will help you in this situation (Reising, 2012).

Why do we place so much importance on accurate/timely documentation? Two of the three most frequent allegations against nurses in medical liability claims deal with documentation. The first relates to the absence of documentation regarding treatment and the second relates to the timing of the documentation, e.g. late entries, and the third relates to Chain of Command implementation. (Keris, 2014).

Documentation is the first thing scrutinized in medical liability claims dealing with nurses. The statement “if it was not charted, it was not done” is frequently argued by the plaintiff’s legal team. Additionally, the plaintiff’s team will argue any documentation entered hours or days after treatment is “self-serving” or different than what may have been charted at the time of treatment. Both legal arguments center on the nurse’s credibility (Keris, 2014).

It is of utmost importance that you document accurately and clearly, know your facility’s policy and procedures, and follow national standards of care when caring for your patient population. To learn more about this important phase of nursing care, review the course: Professional Nursing Documentation.

Take The Course

Keris, M. (2014). What are the most common allegations towards nurses?
Reising, D. (2012). Make your nursing care malpractice-proof. American Nurse Today, 7(1), 24 – 29.