Charting for the Jury: Fine-Tune Documentation for Hospice & Home Care

The true importance of documentation is to improve patient care. When records are kept carefully and consistently, the treatment team provides better care. The care experience is a significant event in a patient’s life. If a malpractice suit is filed, the patient will recall the “facts” in minute detail. However, a caregiver’s recollections may be considered unsubstantiated if not properly documented – even if based on standard practice. The patient’s recollections are unsubstantiated, but patients are not obligated to keep records. Fortunately, concise recordkeeping that accurately reflects the care provided and related reasoning carry greater weight with a jury, unless the records are discredited.

In court, the patient’s attorney will often ask how many patients you care for during an average day. That number is then multiplied by the number of days, weeks, and years since the time in question. With so many patients, how can you remember this situation so well? Who did you care for after this patient? Which nurses were on duty that day? What time did you get back from lunch? These issues have nothing to do with the malpractice suit but can influence the jury to give the patient’s memory more weight. Medical records will be your best friend or worst enemy in the courtroom. If properly prepared, they are the best, and sometimes the only, defense during malpractice litigation.

This informative session is designed for all personnel who document patient care, quality improvement directors, medical and nursing directors, risk managers, and leadership.