How documentation could come back to haunt you.

The confusing or opinionated words you choose in charting today could come back to haunt you tomorrow.

Sometimes, seemingly harmless bits of information you write in a patient's medical record can hurt you in a lawsuit. For example, certain terms such as "by mistake," "accidentally," "miscalculated," or "confusing" conjure up images of nursing errors and compromised patient safety. To prevent problems when writing your nurse's notes, don't use words that express an opinion. Instead, document only the facts.

Here's a good example of factual documentation, made after a physician ordered 50 mg of Demerol:

Patient was given Demerol 100 mg I.M. at 1400 hours for abdominal pain. Dr. Shaw notified but gave no orders. Pt.'s vital signs remained stable.

This entry is a factual account that lets others know the physician's order for 50 mg of Demerol wasn't followed.

_{This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and Aon, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.

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The policy covers your employees outside the office as long as they are performing covered professional services on behalf of your business.

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.

There are plenty more where those came from.

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