What Kind of Story Does Your Documentation Tell?

We often work with hospital nursing and risk managers eager for tips about how to convey to employees the importance of documentation.  Sometimes the old maxim, “If it isn’t documented, it didn’t happen” doesn’t fully resonate with caregivers until they're suddenly on the wrong side of an overzealous plaintiff’s attorney or a suspicious group of jurors.

We encourage caregivers to think of the documentation as “the story” of the patient’s care – and, equally, the story of your care of the patient.  Should someone months or years later want to hear that story, all the necessary pieces should be there in the medical record.

The question to put to caregivers is, “What kind of story do you want to tell?”

Medical records with gaps of several hours where nothing is documented can imply nothing happened and there was no care provided.  But jurors should understand that even during relatively uneventful periods in a patient’s care, things are happening – vital signs are being taken, drugs given, therapies provided, doctors consulted and family members updated.

Documenting even seemingly routine events – such as a nurse sticking her head into a patient’s room to check in – tells the story of an attentive caregiver paying close attention to the patient.  This documentation need not always be lengthy, detailed or time-consuming; sometimes noting a time and adding a few words are enough to fill in the blanks in the story and bolster a trial timeline.

Some may think of this type of practice as “defensive documentation” – and maybe it is – but this is the world we live in.  If each patient’s medical record is a story, then failing to document the “routine” and the “minor” is like tearing out pages – and leaving the real story open to interpretation.

If you have a tricky case involving incomplete documentation, or would like to discuss how we can present to your group on this subject, contact Senior Vice President Claire Luna at 714.754.1010 or cluna@juryimpact.net.