[Nurses' patients' clinical record sheets; complying with legal requirements]

This article describes a 100 page long descriptive study based on nurses' clinical record sheets at three hospitals to discover the degree of compliance with legal requirements. Compilation of existing laws and a specialized bibliography provided the variables for this study. These were placed inside a data base which, once the information from each clinical record was introduced, made it possible to draw conclusions. Due to the socio-linguistic context, the language used and the linguistic interferences were also analyzed. This study showed there is a high rate of non-compliance with legal requirements. The impossibility to identify the professional who fills in each record sheet, low legibility the frequent use of abbreviations, initials, and symbols, crossed out illegible words, and unfinished record sheets have been noted in this study. The results of this study pose the possibility to make available in hospitals a list of legal requirements and of abbreviations, initials, and symbols employing a unified meaning.

Documentation do's and don'ts

TO SAY THAT THE MEDICAL RECORD is one of the most important parts of a lawsuit would be an understatement. No matter how good a witness you are, a jury or a judge will give more weight to a written record. The medical record is the documented history of a patient’s medical condition and care. Without it, diagnoses, continuity of care, and treatment could and would suffer. When treatment fails or goes awry, that same document can give clues about what possibly went wrong, but it can also tell what was done and done right.

Concept analysis: malpractice and modern-day nursing practice

TOPIC

The concept of malpractice can mean different things depending upon the context in which the term is used. This can lead to confusion about the standard of care required for nurses engaged in modern-day nursing practice.

PURPOSE

This paper examines the attributes and characteristics of the concept of malpractice using Walker and Avant's (2005) eight-step methodology.

SOURCES OF INFORMATION

CINAHL, PubMed, and PsychINFO.

CONCLUSIONS

Exposure to malpractice liability is an unfortunate consequence of modern-day nursing practice. An understanding of malpractice will assist nurses in identifying situations that may expose them to legal liability and hopefully lead to improved patient care.

[Forensic nursing in Germany? Nurses' perceptions of domestic violence]

More than one of three women has been a victim of domestic violence at least once. Victims would like to have a well-informed contact person within the healthcare system who knows about support programs. In many countries that is the responsibility of the healthcare system and is called Forensic Nursing. Therefore, it is interesting to know how nurses in Germany perceive domestic violence and under what circumstances they could imagine taking on tasks in the fields of documentation and nursing. The data for this qualitative study was collected via four focus groups consisting of 38 nurses--3 men and 35 women--with work experience in a hospital. Nurses seem to have difficulties in recognising domestic violence. Whether the subject of domestic violence is addressed explicitly depends on the relationship built up between the patient and the nurses. Nurses do not necessarily take further steps. They could imagine providing help by listening actively, providing information about support programs and providing consulting services. Only occasionally nurses agree to document the case to be used as forensic evidence. Another open issue is appropriate remuneration. It is necessary to integrate that subject systematically into basic and advanced training on different levels of qualification.