Legal Risks in Nursing Documentation – Use Extreme Caution When Skimming the Facts – Rosale Lobo

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The nurse was so busy that day. You know how it goes… She didn’t even have time to eat.

It was the day shift and there was a flurry of orders coming in and some were being changed soon after. She had to admit, it was difficult to keep up. She doesn’t recall all the details, but she does remember how scared she felt when the family came in complaining, questioning every medication and treatment she was administering, and fishing through the trash can for discarded “evidence”. Then they asked to speak with patient relations. It was another 2 years before she was called into a lawyer’s office to discuss the care she provided that day.

It is no secret there is an intimate connection between what we chart, how we care for patients, and patient outcomes. What is that connection? How does what you chart – or don’t chart – about a patient become the facts in a nursing malpractice case? Mistakes and near misses happen often. You know there is only so much you can do in a shift. Rosale Lobo PhD, RN, LNCC, will give you expert tips on how to decrease the legal risks that nurses all too often encounter.

1. Recognize why skimming the facts can damage your license.
2. Dissect the connection between your charted words and the truth.
3. Examine the lawyers view on your documentation.
4. Transform your understanding of “trust but verify”.
5. Analyze legal cases to become an expert at charting.
6. Compare your previous charting with your future charting.

The Truth About Documentation (that nursing school never taught you)

• The care plan: Facts vs. fiction
• Clinical application and critical thinking: What the attorneys don’t want you to know
• Learning to think defensively

10 Facts About Being a Nurse Litigant

• The emotional turmoil associated with litigation
• The scenario that lasts a professional lifetime
• There is such a thing as being prepared for questioning

Nursing’s Role in Increasing Safe and Effective Healthcare Delivery

• The increasing demand for accountability
• The regulations that effect their bottom line – and our sanity
• Using the correct “tone” to communicate your message