Critical Documentation
Be alert to the possibility that critical documentation concerning the liability issue may not be found in nursing notes. Very often treatment may be in other ancillary records such as flow sheets, treatment administration records, the notes of physical or occupational therapy of the Minimum Data Set (for nursing home cases). It is very important to stress that experts need to review all parallel sections of a chart before a criticism arises related to lack of treatment.
You can read more practice tips in my chapter Screening the Nursing Malpractice Case, in a text edited by Patricia Iyer, RN MSN LNCC. More information about Nursing Malpractice, Third Edition, 2007 may be found at here.
