Many times in reviewing a clinical record, simple items (e.g., date and time of assessment) are missing. Although it may seem inconsequential to the nurse, these missing pieces may become critical in a court of law. Questions will undoubtedly be raised against the nurse, including:
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How can you prove that your documentation entry was timely?
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How do you prove that your assessment and intervention were based on the patient’s condition at that time?
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What if those preceding you also did not document the date and time?
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Does this show a pattern of documentation that is unsafe?
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Does this demonstrate clinical documentation is not valued?
It’s well know that nurses do not like to document—whether it’s in paper or computer format—but proper documentation is the key to keeping yourself free and clear of legal repercussions.
Source: Stressed Out About Your First Year of Nursing, HCPro, Inc., 2006.
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