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.

Frequently Asked Questions

You have questions. We have answers. (It's why we're here.)

What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 

The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 

How does a shared limit policy work?

A shared limit policy is issued in the name of your professional business or company. The policy provides professional liability insurance coverage for the business entity named on the certificate of insurance and any of the employees of the business entity, provided they are a ratable profession within our program. Coverage is also provided for locum tenens professionals with whom the business entity has contracted for services the locum tenens performs for the business entity.

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.

We have a shared limit policy. Are employees covered if they practice outside our office?

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.

See more FAQs

NSO Learning Center

More insights from some of the best minds in nursing.

Documentation: proactive prevention of litigation.

There is no quick and effective antidote to malpractice allegations. Prevention, however, is necessary.

3 Common Nurse Charting Mistakes to Avoid (Part 1)

Accurate and complete patient chart information is essential to providing the highest possible standard of care. Here are simple tips to improve nurse charting, protect patients from treatment error and prevent potential malpractice liability.

4 Common Nurse Charting Mistakes to Avoid (Part 2)

Following nurse documentation best practices helps keep your patients safe and ensures that you are complying with your employer’s policies – and avoiding potential legal consequences such as a malpractice lawsuit.

Abbreviations in Documentation: A shortcut to disaster for Nurses

Trying to save time by using abbreviations? Make sure that you aren't putting yourself or your patients in jeopardy.