Document, Document, Document

On a weekly basis, I speak with a client, or potential client, who explains to me that the Nursing Board complaint against them is unjustified because they did not fail to administer the medication, assess the patient, administer a treatment, call the physician, etc.; they just forgot or didn’t have time to document the action in the patient’s medical record.  And while I have no doubt that the nurse is being truthful in the assertion that the nursing action was completed as ordered, I am forced to explain that the mere failure to adequately document the nursing action in the patient medical record may result in a finding of unprofessional conduct by the State Board of Nursing.

The Colorado Nurse Practice Act defines unprofessional conduct to include negligently failing to make essential entries on patient records. Additionally, the Colorado Nurse Practice Act requires that nurses meet the generally accepted standards of nursing practice, which arguably includes proper documentation.

Nurses are facing increased patient loads, institutional pressure to avoid overtime, and in many cases, computerized medical record systems. Understandably, when stretched thin, the nurse focuses on actual patient care duties, leaving documentation to take a “back-seat.”  This is not only dangerous to the patient, but also the nurse.

Proper documentation protects the nurse when the care and treatment of patient is called into question.  Courts and regulatory agencies often rely on the old adage “If it is not documented, it wasn’t done.”   The nurse is then forced to prove the nursing treatment was administered and the problem is merely inadequate documentation.  In a regulatory setting, this argument still leaves the Board with the option to discipline the nurse for the inadequate documentation.

Nursing liability insurance carriers often post risk management tips for documentation on their websites.  Links to some of the tips posted by Nurses Service Organization are included here.  A few of the tips relate to “paper” charting but can be easily modified for electronic documentation.

This post is intended as informational only and does not constitute legal advice. If you, or someone you know is facing disciplinary action against their nursing license, consult with an experienced Colorado Nurse Defender before making any statements.

The Law Office of Karen M McGovern, LLC, is an experienced law firm specializing in Colorado nursing license defense . Call 303.260.6444 for a free consultation or contact us through our website – www.mcgovernlawoffice.com.

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