Documentation for home health care

Avoiding malpractice is more than avoiding a lawsuit, it is avoiding the litigation process altogether. Proper documentation is arguably the most important element in avoiding malpractice and litigation for nurses. There are many reasons why nurses spend much of their time charting. However, when it comes to malpractice and the litigation process, documentation may be the only evidence a nurse has to defend his or her position.

By the time a lawsuit is filed, chances are the nurses will not remember the particular patient involved, especially if they only cared for the patient for one or two shifts. Even if the nurses do remember the patient, it is their documentation that will be reviewed, presented and relied on, not their memory.

All nurses have been taught, “If it’s not written, it’s not done!” But, what exactly does that mean? Whether you are a student nurse or have been in nursing for thirty years, this question may be difficult to answer.

Over the years, documentation has changed a great deal. But, the rationale behind why documentation is important remains the same. Whether you are documenting with a narrative style, using flow sheets or charting by exception, the purpose of documentation is to memorialize what occurred while you took care of your patient and to capture relevant information about the patient’s condition and medical history. The more accurately your documentation depicts what actually happened during the time you took care of your patient, the more likely you are to avoid becoming involved in litigation for malpractice.

Regardless of the type or style of charting a nurse uses, it is important for documentation to be legible, logical, and complete. Not only to prove what occurred, but to also show what did not occur. For example, if a patient is admitted to a facility with both arms in tact, and claims to have left the facility with a broken arm, the first thing the patient’s attorneys and their experts are going to do is review the medical records. They will try to determine from the records when and how this patient’s arm could have been broken.