Standing up to the scrutiny of medical malpractice

Correct charting, updated policies and procedures, and firm staff understanding are critical components of avoiding medical malpractice.

Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district

The aim of this study was to investigate the adherence of nursing documentation to clinical guidelines in leg ulcer patients. Using two audit instruments, 100 patient records from primary health care were reviewed. The nursing content in the records was assessed according to instructions for documentation in local clinical guidelines for leg ulcers and the comprehensiveness of the nursing process in recording was reviewed. The results indicated deficiencies in the documentation of aspects of relevance in the care of leg ulcer patients. In addition, the findings indicated flaws in the adoption of the nursing process in recording. Only one problem in one patient record was recorded that consistently used the nursing process. The conclusion is that, despite specific and locally developed guidelines for care of leg ulcer patients, nursing records did not provide a precise audit of the care process. Because patient record information without a clear structure following the nursing process tends to impede communication and evaluation of care, such defective information is likely to have a significant impact on the continuity and quality in patient care.

The clinical record

Documenting completely and accurately is standard nursing practice, yet many nurses do not seem to understand that proper documentation is crucial to the communication and critical decision-making necessary to meet patients' needs. In fact, failure to document can have lethal consequences. Documentation of intake and output (I & O) is used here as an example of the evidence attorneys and nurse experts look for in the clinical record of elders. From exhibits of I & O records, juries can determine if nurses collected sufficient data for appropriate decision-making to protect the patient from harm. Readers are invited to test themselves to determine if their own I & O documentation meets acceptable standards of nursing practice. If readers find areas for improvement, self-study or group in-services can be held to improve the documentation and use of these data.

Legal concerns in tissue viability and wound healing

In an age of increasing litigation, it is important for tissue viability practitioners to be aware of the legal issues surrounding their practice. Bridgit Dimond discusses some of the legal aspects that were raised as concerns by participants recently attending a post-graduate diploma course in tissue viability and wound healing. She clarifies the main legal requirements for healthcare professionals working in this field.

The importance of good record-keeping for nurses

Good record-keeping is a mark of the skilled and safe practitioner, yet allegations concerning shortcomings in nurses' record-keeping were the second most common category of hearing brought before the UKCC in 2000-2001. The absence of accurate records makes it difficult for practitioners to prove they provided appropriate care should they be asked to do so in a professional or legal hearing. This is particularly pertinent since litigation against health professionals is increasing rapidly. This article discusses the importance of keeping comprehensive and accurate records of patient care and decisions from the perspective of nurses, their patients and colleagues. It also discusses the elements of good record-keeping, as well as practices to avoid.

Falls.... A prelude to litigation

For years long-term care has found itself vulnerable to law suits. This is still true today. On any given day, nursing homes and the staff employed by them are only one unhappy client away from receiving a notice of intent. In today's litigious world, nursing homes must have in place, effective policies and procedures to minimize their risk for a lawsuit. Part of managing the risk, is having a multi-disciplinary team in place that takes a proactive approach to patient safety. The particularly high risk patients for incident are ambulatory patients with cognitive impairment. The multi disciplinary team must aggressively address each of these residents in relation to their fall risk. Implementation of a comprehensive plan of care, maintaining good communication between facility and the patients' physicians and families, and quality charting by the nursing staff, are some of the key elements in preventing litigation.