Forensic Nursing And Charting

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Documentation in the nurse’s notes is essential in evaluating patient care and outcomes. It is a legal document and will be used in a court of law if a lawsuit is initiated by a patient or family member.

The Forensic Nurse uses nurse’s notes as a means to obtaining evidence in court pertaining to the patient involved. As I read through the “Basic Pharmacology for Nurses” textbook, it is evident in each chapter that charting is documented proof of patient care. Evidence of patient care and treatments, outcome of treatment, health teaching and effectiveness of teaching needs to be documented. We learn this all in nursing school.

Marianne DeMilliano BSN, JN describes “Eight Common Mistakes to Avoid when Charting” which is available at http://www.nso.com/newsletters/features/common.php

These mistakes can be avoided and definitely will help a nurse if she ever winds up in court.

With regards to Pharmacology and Nurses, the sixth right of medication preparation and administration is “Documentation”. As discussed in one of my previous posts called “Medication Errors”, documentation of date, time, drug name, dose, site and route of administration is important. Further documentation is required in the nurse’s notes to indicate a patient’s response from the medication. Was the drug effective? Did the patient exhibit any adverse effects (psychologically or physiologically) from the drug? Was there any reaction to the site where the drug was administered? Is the patient’s level of pain pre and post medication documented as per a pain level scale? Was the physician notified of the patient’s response to the medication? Did the physician assess the patient and change the medication order? When a new medication was administered, what was the effect of the medication?

Failing to record nursing actions and failure to record reactions or changes in the patient’s condition is just one of many mistakes Marianne DeMilliano discusses in her article. Other mistakes she notes is failing to record pertinent health or drug information, failing to record that meds have been given, recording on the wrong chart, failing to document a discontinued medication and transcribing illegible or incomplete orders.

Nurse’s notes will aid the Forensic Nurse in obtaining specific content relevant to evidence required for investigational purposes and for use in a court of law.

Forgetting to document patient information means “If you didn’t chart it, it didn’t happen”.

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