RELEVANCE OF NURSING DOCUMENTATION AND ITS LEGAL IMPLICATIONS With recent development in health care delivery, where clients

are becoming more conscious of their right to proper health care services and, therefore, can sue the provider if they believe there was negligence or malpractice in the rendering of the service. In this vain the nurses need to be conscious in the provision of standardized care that is backed with proper documentation. In order to be exonerated in case of any legal action against him/her and the institution. If you were required to testify in court in defense of the care provided to a patient, would your documentation be adequate to protect you from legal liability? If the care you provided came under scrutiny months after it occurred, would your documentation enable you to accurately describe the standard of care delivered to the patient? The term documentation according The Mosby Pocket Dictionary of Medicine, Nursing and Allied Health refers to the recording of pertinent patient data in a clinical record.In a related literature, The College of Registered Nurses in British Colombia (CRNBC) also referred documentation is any written or electronically generated information about a client that describes the care or service provided to that client. Client here refers to individuals, families,groups, population or entire communities who require nursing expertise. Documentation allows nurses and other care providers to communicate about the care provided. Documentation also promotes good nursing care and supports nurses to meet professional and legal standards.

Nurses are subject to increasing scrutiny regarding their record keeping. Legislation such as the human right act 1998and the data protection act 1998 has increased the profile of and access to health rewards whiles the patients are increasingly willing to complain about their care. Whether complains are resolved by health care providers or settled in court, comprehensive records are essential (vol.99 issue; 02, page no. 26) For proper documentation, the main factors need to be ensured namely; recording and proper maintenance of the records or documents. In nursing documentation include; front index sheet, temperature chart, fluid input and output chart, nursing notes, ward reports, annual and half year report, incidental report, admission and discharge book, patograph, consent form among others. The medical records play a vital role in most law suit involving nurses. If the medical record shows that the patient receives reasonable care. It may prevent a law suit. On the other hand, if the record is poorly documented a patient may sue and win even though he may have actually received reasonable care. The nurses notes are virtually the key to the evaluation. Legal Perspectives The cost to the NHS of litigation rose from 2.3bn in 1998 to 4.4bn in 2001 (National Audit Office, 2002). Litigation is already regarded as an occupational hazard for medical staff, and it is estimated that at least one in three other health professionals will be involved in some kind of legal proceedings at some point in their career. Law courts adopt the attitude that if something is not recorded, it did not happen and, therefore, nurses have a professional and legal duty to keep records. The NMC (2002c) states that documentation should demonstrate:

 A full account of the nurses assessment and care planned and provided for the patient. Relevant information about the condition of the patient at any point. Measures the nurse has taken in response to the patients needs. Evidence that the nurse has understood and honored the duty of care, has taken all reasonable steps to care for the patient and that any action or omission has not compromised patient safety. A record of any arrangements the nurse has made for the continuing care of a patient or client. Nurses face new issues and problems each day and regularly make decisions on patient care. Each decision is potentially subject to review with the publics increasing awareness of their rights and tendency to litigate. Amid the stress of a working day, it is easy to see how record-keeping might be seen as a chore that gets in the way of patient care. However, it is an integral part of care. Nurses must allocate time for both hands-on care and documentation, as it is the two together that constitute total patient care. If record-keeping is seen as a chore, there is a risk that the documentation will fall short of the standard expected of a professional. A nurse who has cared for hundreds of patients could not possibly remember details about the care provided to a particular patient several years or even several weeks later. However, the circumstances are likely to be fresh in the memory of the patient making the complaint. Good documentation can therefore be a vital means of recollection for nurses faced with litigation. Detailed and substantial evidence is likely to be influential in such circumstances; nurses whose memories of events are poor and who have not documented their actions clearly may find

their position compromised. Having good quality records to refer back to enables the nurse giving evidence to relate as precisely as possible what happened. Long before a legal case becomes a formal hearing, the nursing notes will have been read and studied and an impression formed regarding the relative professionalism of the author. If records are clearly unprofessional it is easier to extrapolate that the same lack of professionalism would be reflected in attitudes towards patient care. Any notes or records taken in the course of a nurses work are a potential legal document and could be used in court. If they contain judgmental, vague or unsubstantiated information, it becomes difficult to maintain professional credibility in court. It is the job of a patients lawyer to undermine a nurses case by casting doubt on that nurses credibility. Lawyers are familiar with court cases and professional hearings - two scenarios that may be extremely intimidating for those who are not. Purpose for Documentation Communication: Clearly documented information on a client, tells the plan and progress of care given to the other members of the health team. Assessment: Information gathered from clients record is used for comparing clients initial assessment with present history will aid in progressive assessment to enable the achievement of goals. Care plan: Formulation of a care plan flows from the assessment or information from the clients record. Education: Members of the healthcare team including the student nurses, medical students and other disciplines use the clients records as an educational tool. It has

valuable information such as signs and symptoms, diagnosis, diagnostic tests and treatment modalities. Research: Nursing research is often carried out by studying client records. Data gathered from groups of records may help to determine similarities in in disease presentation, contributing factors and effective therapies. This helps to plan strategies. Legal documentation: It may be used to prove or disprove a case against or implicate or absolve a health care professional for improper care. Quality assurance: The patients record is used to monitor or measure the quality of care being given. Are the cares given standard? Reimbursement: Documentation helps the facility too receive money from the government and the insurance companies especially now that the national health insurance scheme is being implemented. Characteristics of Good Documentation Accuracy: One must write only observations seen, heard, smelled or felt. An observation made by another person must be clearly identified as such. Use precise measurement and terms when possible, e.g. Describe a wound as 3cm or 5cm rather than small. Completeness: All data that a nurse obtains can be recorded. However, information recorded needs to be complete and helpful to the client and nursing process, e.g.Client problem, intervention, patient response and if there was communication with other members of the health team.

Legibility: Writing must be clear, easily read by others especially figures and medical terms, e.g. dysphagia; difficulty in swallowing, dysphasia; difficulty in speaking. Timeliness: Documentation should be timely to avoid errors. Record all medications given, procedures, treatments and assessment done just after completion. Conciseness: Writing should be concise and brief. Use acceptable abbreviations eg, good charting. Objectivity: Using direct quotes of clients statement can help maintain objectivity e.g. client says misses friends and are no longer visiting than client is lonely and frustrated. Organization: Documentation should flow chronologically. Client care should be documented according to time procedures completed with client reaction. Types of Documentation 1. Front index sheet 2. Temperature chart 3. Fluid intake and output 4. Nurses notes 5. Ward report 6. Annual report 7. Incident report

Nurses Notes/ Point of Care Documentation Nurses note is a report of the interventions carried out on the patient and its outcome. The notes should include: Patients particulars Date and time of writing notes New or change of information Signs and symptoms client behavior Nursing interventions Medication given Client teaching Client response The nurse must sign under the written intervention. Precaution: o Notes must be legible, timely, accurate, complete and concise. o Use only simple and standard abbreviations. o Avoid the use of correction fluid. o Where there is an error, cancel it neatly and sign against it. o Do not leave blank spaces. o All information must be kept well. o Ensure confidentiality of information. Conclusion Just as you should never chart medications given by someone else, never document an action performed by someone else. If a nursing assistant participates in direct

patient care, they should chart those activities in the medical record. Remember that all health care providers are accountable for their own actions, whether they are professionals or non professionals. Nursing care actually provided may have been excellent, however, in the court of law care not documented is care not rendered.