August 01, 2014

Of the top three most common allegations towards nurses in medical professional liability claims, two deal with charting.  The first related to documentation is that in the absence of documentation regarding treatment, the treatment did not occur.  The second criticism centers on the timing of the chart entries and that if an entry is late, the nurse is accused of documenting self-serving care.  The third most common allegation deals with "chain of command" issues in that the nurse should have second-guessed the care rendered by physicians in a hospital setting and have someone intervene on the patient’s behalf.

Charting is where nurses are scrutinized most often.  Plaintiff lawyers will argue that if a nurse does not document a test, examination or finding, it was not done.  Often times, that is not the case and there are multiple areas in the chart that can memorialize a test result, finding or intervention---it may just not be documented in one particular area.  As such, time should be spent by the nurse and counsel in closely examining the chart to ensure that an accurate depiction of the care rendered can be made.  In the absence of documentation in the chart, nurses should also consider what their common practice was in similarly situated patients.  Timing of chart entries also poses risks because it can be argued that late documentation can be jaded or influenced by the passage of time.  In other words, the choice of descriptive terms used by a nurse hours after care is rendered may be different from the words used if the documentation was simultaneous to the care, depending on how the patient fares.  In both charting scenarios described above, the issues center on nurse credibility.  

The area of most clinical scrutiny deals with whether a nurse should have intervened on a patient’s behalf and makes a call "up the chain of command" and have other physicians become involved in the care.  This is a difficult proposition because if the nurse believes that other intervention was required, but did not act on this impression, it was a deviation from the standard of care.  Conversely, if the nurse did not believe that a "chain of command" call be made, they will share in the criticisms lodged toward the physicians.  Proceed with caution with all "chain of command" decisions. 

Matthew P. Keris