The Importance of Accurate Documentation for Forensic Nurses

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I mentioned in a past discussion that nurses are already forensic nurses: Anything we document can be used as evidence in a court of law. Good documentation will help defend ourselves in a malpractice lawsuit; it can also keep out court in the first place.

According to “8 Common Charting Mistakes To Avoid” (July 1992) Marianne DeMilliano, BSN, JD, http://www.nso.com/newsletters/features/common.php

1. Failing to record pertinent health or drug information.
2. Failing to record nursing actions.
3. Failing to record that medications have been given
4. Recording on the wrong chart.
5. Failing to document a discontinued medication.
6. Failing to record drug reactions or changes in the patient’s condition.
7. Transcribing orders improperly or transcribing improper orders
8. Writing illegible or incomplete records.

A long time ago, while I was working in a hospital, I was concerned about how much time I should spend documenting. One of the nurses there was documenting every detail about her patient on the chart. I wondered whether she didn’t miss out on some of the nursing process and perhaps some action she should be performing. It took her such a long time to do such detailed documentation. I know that many nurses complain that there is no time to document. It is important to know how and what to document.

We should chart patient care at the time we provide it, but many times the charts are completed long after the care has been given. Community nurses (Public health nurse) have an easier time documenting at the time care is provided than hospital nurses, because of the patient ratio or acuteness..etc. Still, most of the current charting does not meet the demands of laws and regulations.

Recently, computer-based environments are replacing or being used in conjunction with paperless charting. The jury is out on the total effectiveness yet, but there are obvious advantages and disadvantages to computer-based documentation. I believe that computer-based charting and documenting is a little easier because often a box can be checked instead of writing every item. I hope this will end up giving us more accuracy, decrease mistakes, and provide a record that can be used as good evidence.

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