The gold in nurses’ notes

Attorneys, legal nurse consultants and experts carefully examine nursing notes. Here are 4 top reasons to do so.
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 LNC 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.

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.

This blog post is extracted from Nursing Documentation, a chapter written by Pat Iyer and Sharon Koob, in the fourth edition of Nursing Malpractice. See our webstore for details.