If You Didn’t Document It… | OnlineLPNtoRN.org

Originally published at http://onlinelpntorn.org/2014/if-you-didnt-document-it/

Write everything down to save yourself from trouble later!

...it didn't happen. Right? Typically that statement is bandied about regarding patient documentation; however, lately I have been hearing another side of it. I suppose we could call it self-documentation.

I have been reading blog posts written by nurses in trouble, and they say their attorneys have told them that nurses should document everything they do. What about if the worst case occurs and you are accused of something you didn't do? Could you defend yourself?

Nurse legal consultants say to keep copious notes on everything you do so that you can bust them out if you're ever accused of evildoing. That sounds like a fantastic idea, but it's totally impractical and has real-world limitations and concerns.

The first and most obvious issue is how are you supposed to know what is going to land you in trouble so that you can keep notes on it? I have received only one patient complaint that I knew was coming, so I had charted the heck out of the entire patient encounter. The rest of the time, it is a truism that the patients who complain are the ones who have given absolutely no indication that anything was wrong. (Conversely, the ones who shout and have tantrums typically don't complain.)

Who will sue? Patients are starting to sue nurses more often. Once mainly a physicians' realm, nurse lawsuits are picking up as a litigious public realizes that there is money to be had. Even if you are not sued per se, you may find yourself involved in licensure or other disciplinary issues. The irony if you are innocent is that you didn't document anything because you didn't do anything. It is absurd to be expected to document randomly on something you are not doing. "Today I did not do this thing that I will be accused of in 6 months." It's just not possible.

Yet unfortunately, if you are accused, your accuser will no doubt have notes that you did do that thing. The sad reality is that people can say you did whatever they want to say you did, and if your only defense is "huh-uh," things will go badly.

I pause at this point to defend myself against readers who may be thinking I'm a crazy paranoid lady. I know some of you are, because I would have thought so myself before I encountered the dark side of nursing. I assure you that unscrupulousness pervades nursing and hospital administration just as much as it does angry, money-hungry patients with a score to settle.

My one legal nurse consultant friend recommends that all nurses keep notes on what they do each day. What about HIPAA? You can't leave your notes at work, because if you get fired you can bet you won't get them back. So, since you'll be carrying them in and out of work, ensure your notes are HIPAA-fied (that means not that the patient could not identify him- or herself, but that others could not identify who it is, by the way) or you'll have even more problems.

How to take notes against nonexistent things you may be accused of at some point? She recommends a work journal including your shift assignment, any different things that happen, and particularly anything that strikes you. A funny look from a charge nurse or a heavy silence from a physician can mean something: trust your gut. Write it down, including what you were doing at the time. Even if you can't project what will happen later, paying attention so that you can write down your shift plus including memory-joggers are surprisingly helpful at bringing back the rest of that shift into focus if needed.

Finally, if you don't already have your own liability insurance, get it. It's cheap and will be some help if you find yourself mired in disaster.