Styles of Record Keeping & Risk Managenment Strategies to Avoid Legal Problems
Barbara E. Calfee, JD, (Lawyer) is Dynamic, Brillant and Dedicated to the legal guidance and support of health care professionals. A Legal Assesment Guide for Nurses as well as legal columnist for Nursing; she has written exclusively for the defense, support and education of health care professionals. Barbara Calfee has spoken to more the 50,000 nurses and leaves her audience laughing and learning at the same time. Barbara takes the fear out of your practice by giving you confidence and security.
How to prevent legal problems related to inadequate assessment, poor planning, and intervention errors.
Although you may never find yourself facing a jury, the following cases illustrate how common nursing mistakes can lead to malpractice lawsuits. The lessons learned by the nurses involved can help keep you out of a courtroom.
Inadequate assessment: Assessment errors are involved in most malpractice cases against nurses.
Another physician at the hospital examined the girl 2 days later (on a Saturday) and discovered she'd developed compartment syndrome. He tried to reach the surgeon, not knowing his colleague was inaccessible by phone over the weekend.
The second physician then contacted the hospital's medical director, who gave him instructions on how to treat the girl. Later on Saturday, the girl underwent an emergency fasciotomy to relieve pressure on blood vessels, nerves, and muscles.
Although the girl can walk, her leg no longer functions normally. Her mother sued the hospital for damages.
WHEN YOU'RE BUSY, DOCUMENTING EVERY DETAIL MAY seem less important than getting your work done. That can lead you to chart vague or potentially misleading generalizations instead of appropriate details. Avoid this charting pitfall by making sure that your narrative notes include:
*specifics about the patient's abilities and needs and your interventions-including quantities, time frames, distances (for example, if your patient is beginning to ambulate), and pertinent patient comments. For example, write that your patient walked 20 feet independently with a steady gait and good balance. Avoid general statements, such as she was "ambulating well." Your notes should show that nursing interventions are appropriate for the patient and clue other caregivers in to the patient's abilities and needs. *any precautions other nurses should take to prevent a patient injury or incident-for example, keeping side rails up or assisting with ambulation
"Let World Class Speakers & Entertainers enhance your next event by providing the appropriate speaker or entertainer to fit your program and budget requirements."
- Joseph I. Kessler, President
Connect with me on LinkedIn