In nursing, the rule is, “if it isn’t documented, it didn’t happen.” While that phrase may sound harsh, it’s a reality that can affect many medical malpractice claims.
Memories can fade, witnesses leave for other positions and patients transfer to different facilities, but the charts remain – and they can be among the most important pieces of evidence that factor into the evaluation of a patient’s care when there are allegations of malpractice. As such, charting errors can be critical issues in more than one way. Some of the most common charting errors happen because the health care environment is often chaotic and stressful. They include:
1. Delayed charting
Nurses may intend to update their charts later, after they’re done handling urgent patient needs, but delayed entries can raise concerns about the accuracy of the notes and the timing of the care.
When documentation is entered hours after an event, attorneys and expert witnesses may question whether details were forgotten or reconstructed after the fact. Delayed charting can also create confusion about when a patient’s condition changed or when interventions occurred.
2. Vague or incomplete documentation
Brief phrases like “patient stable” or “resting comfortably” may not provide enough detail to explain what was actually happening with the patient.
Good charting is usually specific and objective. Documentation should reflect what the nurse observed, what the patient reported and how the patient responded to care. Specific details about symptoms, complaints, behavior or changes in the patient’s condition often become important later if the patient’s care is questioned.
3. Failing to document communication
Communication issues appear in many malpractice cases. Nurses may appropriately notify a physician or provider about abnormal vitals, worsening symptoms or patient concerns – but conversations that didn’t get documented can be hard to prove. The chart should note:
- When the provider was contacted
- What information was communicated
- Any orders or instructions received
- Whether any follow-ups were necessary
Without documentation, it may appear as though concerns were never escalated at all.
4. Copy-and-paste charting
Electronic medical records have made documentation more efficient, but copying forward old assessments can create major problems with inaccurate information.
For example, a copied note may continue describing a patient as alert and oriented even after the patient’s condition changed. Inconsistent charting like this can become a major issue during litigation and lead to doubts about every note in the record, not just the duplicated ones.
5. Charting opinions instead of facts
Nursing can be stressful, especially during difficult patient interactions – but documentation should always remain objective and professional.
Terms like “difficult,” “noncompliant” or “drug seeking” can create problems if they are not supported by factual observations. It is usually safer to document specific patient behaviors, illustrative statements and clinical findings that point to those conclusions rather than personal opinions.
In malpractice cases, the medical record often becomes the clearest timeline of events. Careful documentation helps demonstrate the nurse’s clinical judgment, communication efforts and response to patient concerns and makes for a better defense.
