Medical Documentation Negligence : How Risky It Really Is

I found this great article over the net and I thought this might be a good resource for nurses who wants to keep away from nurse malpractices. As a matter of logic, who wants to have a nursing abuse or malpractice case anyways?

This is an article by rose cliffords and I have the greatest respect for her. She knows her craft and I think she is well learned about nursing abuse laws. Just the kind of expertise I need on this Nursing Negligence and Abuse Blog.

The lack of and inconsistent medical record documentation continues to exist in the delivery of emergency department care. Whether the emergency department is busy or not, there seems to be a high number of emergency department records reviewed from a medical legal standpoint either for standard of care issues, personal injury descriptions, justification of payment or evidence of criminal injuries.

In analyzing medical records for more than 20 years, it is often apparent that both emergency department doctors and nurses are challenged to document care delivered in more complete and concise detail. Realizing by the very nature of the specialty area where time is of the essence, it is not surprising to see the continued lack of legible handwritten notes or the sketchy legible clear electronic notes. Either forms of documentation hinder retrospective audits of the emergency department medical record that would help support the evidence that appropriate comprehensive care was in fact delivered or that injuries were related to out-of-facility events.

This becomes a real issue in cases that are evaluated for medical and nursing malpractice or where a personal injury occurred such as in a motor vehicle accident or a work related injury resulting in the loss of a limb that will later need to be explained. Consistent points in issue that make it hard to defend or explain the extent of the injury are:


· Lack of documentation

· Lack of consistent legible documentation

· Failure to document the time care was delivered

· Lack of legible signatures of healthcare providers

· Failing to intervene

· Lack of documenting when consultants are called in

· Rewriting entire entries

· Delays in evaluation, diagnosis, treatment

· Failing to confirm the accurate placement of peripheral intravenous catheters in a vein instead of in an artery

· Failure to confirm accurate placement of central venous catheters prior to use or administration of medications

· Errors in IV administration of medications dosage, dilution, rate

· Lack of communication


Remember the medical record is a tool that all healthcare providers use to communicate any and all care provided to the patient. Its fundamental purpose is to facilitate the continuity of healthcare, but its use lives well beyond the immediate emergency department visit. Article by: Rose Clifford,RN