Charting Tips: Guarding against liability

Good documentation should offer legal protection to you, your patient's other caregivers, and the healthcare facility.

Admissible in court as a legal document, the medical record provides proof of the care received by the patient and the standards by which the care was provided. Medical records typically serve as evidence in disability, personal injury, and mental competence cases. They're also used in malpractice cases, and how and what you document--or don't document--can mean the difference between winning and losing a case, not only for you but also for your employer.

For the best legal protection, make sure your documentation shows that you not only adhere to professional standards of nursing care but also follow your employer's policies and procedures--especially in high-risk situations.

Source: Complete Guide to Documentation, 2nd edition, Lippincott Williams & Wilkins, 2007.