GOALS

• To provide the registered nurse with useful and informative guidelines on documentation.
• To enhance and nursing practice and risk management techniques by the formulation of an objective medical record which adheres to state and federal criteria.
• To educate the nurse on the importance of the medical record if he or she is involved in litigation.

INTRODUCTION

In the courtroom, medical records are the witnesses whose memory never fades. From a legal standpoint, the medical record serves four purposes:

1. Refreshes and improves the recollection of the nurse as to what was planned and done in the patient's care.
2. Communicates important data to all those participating in the patient's care. In effect, it creates a chain of responsibility within the healthcare team and from shift to shift.
3. Creates a legal document regarding the care and course of treatment for a particular patient.
4. Creates a legal document to record and substantiate a standard of nursing care for medicolegal and other reviews such as government agencies and insurance carriers. (2)

The nurse who makes entries in the patient's medical record controls her or his own testimony. It can be your best friend or your worst enemy. The good medical record defends itself and those who prepared it. A good record enables the health care provider to reconstruct the patient's course of treatment and demonstrate that the care provided was in accordance with accepted nursing practice.

The Nurse's Legal Handbook states the purposes of the medical record are

• To help verify quality of care
• To assist in the coordination of care
• To ensure continuity of care
• To seek reimbursements
• To comply with regulations of federal and state government and accrediting organizations
• To provide evidence in a court of law
• To generate data for research