Nursing documentation frequently reflects the most crucial parts of the medical record. If it is meticulous, appropriate and truthful, it supports quality medical care. It can also contradict information found elsewhere in the chart when questions of malpractice or negligence arise. Nursing documentation, whether in a hospital, clinic or physician's office, symbolizes a continuous accounting of signs, symptoms, complaints and the patient's response to physician's orders, treatments and interventions.
Historically, the responsibility for medical care was strictly allotted to physicians. That is no longer the case as the public has become more aware of nursing's role in health care. Nurses are required to do more than simply follow physicians' orders. Nursing responsibilities include patient advocacy, even when the role is adversarial to the physician. Documentation begins the moment the patient arrives at the hospital, clinic or unit and continues until discharge. Documents include a complete nursing assessment, a nursing care plan, which outlines health care needs and goals, nursing interventions and responses and discharge instructions. Nursing documentation furnishes a vital aspect to the continuity of medical care given over a specific period of time.
State and federal legislation and statutes set the foundations for legal nursing documentation. Each state's Department of Health and Board of Nursing also set standards. Nursing practice standards and guidelines help formulate the scope of nursing practice and the level of responsibility the nurse is held to in a legal action. Legal claims against a nurse require evidence of a nurse-patient relationship, which confirms a duty to the patient. Additionally, proof is required that the nurse deviated from accepted practice in her duties and that the patient was injured as a result of the deviation.
Whether documentation is computer-based or handwritten, the requirements remain the same. Clear and concise documentation, finished within an appropriate time frame and based on first-person observations, reflects responsible professional judgment. Nursing documentation includes the facility's choice of forms and adherence to procedures and policies set by the facility. When legal issues arise, the nursing documentation becomes a central part of proving whether standards of care were met or not.
Legal issues in nursing documentation regarding medication records and medication errors are common. When the wrong drug is administered, the wrong dose is given or the wrong mode of administration is used, a medication error has occurred that can have serious consequences for both the patient and the nurse. The failure of the nurse to monitor the patient for an appropriate response to medication, side effects or toxicity can result in harm to the patient. Following the physician's orders does not protect the nurse from legal action if or when the patient is harmed. It is the nurse's responsibility to provide a safe environment for her patient.