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The Dos And Donts Of Medical Malpractice Documentation

Medical Malpractice

As a nurse, it’s really important to document your patient care to the best of your ability and also to do it correctly. 

The reason for this is that if you fail to document correctly, you can put yourself at risk for a malpractice lawsuit. 

See, medical documentation exists for a very specific reason. 

It exists to track patient care and to keep an accurate record of everything that was done while that patient was in the care of the medical facility, doctors, and nurses on site.

And if anything goes wrong, the first place everyone is going to look will be at the documentation—because this should provide an accurate record of everything that was done. 

And the basics of it are this:

If you did everything correctly, and properly documented it, then there’s really no case for malpractice.

But if documentation wasn’t sufficient, or if malpractice was documented in your notes, this can open the door to a malpractice loss. 

Now, it goes without saying that everyone in the medical industry should carry malpractice insurance, especially nurses. 

In fact, if you don’t currently have nursing malpractice insurance, LeverageRX does a pretty good job of describing why it’s important and why every nurse should have it. 

(They also explain it on a pretty in-depth level, so it’s worth checking out.)

With that being said, let’s talk about some of the do’s and don’ts of medical malpractice documentation.

1. Make Sure The Correct Chart Is Being Used

Using the correct chart will go a long way toward protecting you from being accused of negligence with not only charting but also treatment. 

Using the proper type of patient chart when charting is important for a nurse because it helps ensure accurate and efficient documentation of the patient’s medical information, which is critical for providing quality care and avoiding medical errors. 

Additionally, using the proper chart type ensures compliance with legal and regulatory requirements for healthcare documentation.

2. Make Sure That The Documentation Reflects Your Professional Capabilities

It’s really important to make sure that all documentation reflects the nursing process and the full extent of the nurse’s scope of care should be. 

Nursing charting and patient documentation should reflect the nurse’s scope of care and the proper nursing process for that patient to ensure continuity of care and safe patient outcomes. 

It also helps other healthcare professionals understand the patient’s history, plan of care, and any changes in their condition, which is crucial for making informed decisions about the patient’s care.

3. Chart All Medications And Times

You should also chart the administration route, the patient response, and anything else applicable to the administration of medications. 

4. Don’t Make Your Charting Vague

It’s really important to accurately and specifically chart everything. 

You don’t want to describe something, for example, as just ‘painful.’ 

You would want to be very specific about the type, the location, the level on a scale of 1 to 10, etc.

5. Never Alter A Patient’s Record

This is actually a criminal offense. 

Once a patient’s record has been documented, it’s really important to leave it intact. 

Changing it to any degree after the fact will not only open you up to criminal charges, but it could also very well lead to you losing your license and being subjected to malpractice litigation. 

6. Do Not Make Descriptions Imprecise

For example, never describe something as a large amount.’ 

You would want to be as specific about the measurement of the amount as possible.

7. Never Chart Ahead Of Time

Sometimes, nurses may be tempted to chart care ahead of time, to either save time or in an effort to make their schedule more efficient. 

But here’s the thing. 

Situations often change in a medical care situation. 

And charting care that hasn’t actually been performed is actually considered a form of fraud. 

It can get you into a lot of trouble. It can complicate everything to a massive degree, and it can definitely leave you vulnerable to malpractice litigation 


There you have it.

Some important do’s and don’ts associated with medical documentation. 

It’s always important to try to be as careful about charting as possible, to avoid opening yourself up to a possible malpractice lawsuit. 

At the end of the day, striving to do your best to understand the process, and asking questions if you’re not sure about things, are generally some of the best ways to avoid disaster. 

This is especially true when you are facing new situations that you’ve never faced before.

Read more – How To File A Medical Malpractice Lawsuit in Manhattan in 5 Easy Steps

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