Nursing & Healthcare Directories on: The Nursefriendly
Nursing Documentation, Nurses Notes Malpractice Case Studies

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June 13, 1999: Felony Child Abuse Conviction, Made Possible Thanks to Nurse's Documentation.
Child abuse is a "reportable" crime.  This means when a healthcare worker suspects in the course of their duties that a child has been abused, it must be reported.  Procedures are in place in hospitals and other facilities for the reporting of abused children. In this case, it was the expert documentation of a child's statements by a nurse, physician and field agent that made the conviction of an abuser possible.
http://www.nursefriendly.com/nursing/clinical.cases/061399.htm
State v. Gillard, 936 S.W. 2d 194 - MO (1999).

June 6, 1999: Emergency Department Nurse Verbally Abused, Physician History Well Documented
Official tolerance for verbal abuse and sexual harassment is approaching zero.  It is clear that both are still prevalent in healthcare settings today.  Enforcing and reporting instances of abuse are critical to an end being put to the situation.  In this case, a physician had a "history" of verbal abuse in the facility involved.  It was the documentation of previous events that made formal action and administration of a suspension feasible.
http://www.nursefriendly.com/nursing/clinical.cases/060699.htm
Gordon v. Lewiston Hospital, 714 A.2d 539 PA (1998)

See also:

The Best Defense Is a Good Documentation Offense, Corexcel.com:"After completion of The Best Defense Is A Good Documentation Offense, the participant will be able to:
1. Explain the importance of documentation as a health care provider.
2. Identify the basic information that is required when documenting in the medical record.
3. Describe those particular issues that require documentation in the medical record.
4. Discuss the emerging documentation concerns regarding the faxing and computerization of records.
5. Determine documentation Do's and Don'ts."
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Editors Note: The urls to these cases are Permanent and Will Not Change. Feel free to link to any case you feel is helpful. To host any of our cases on your website or reproduce them in your publications, please contact Andrew Lopez, RN

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