Other items related to #Documentation

Do’s and don’ts of defensive documentation in the EHR

Documenting care is a basic nursing responsibility, but it’s one that nurses often struggle with because of time constraints and challenges associated with electronic health records (EHRs), such as poor user interfaces that leave nurses unclear as to where to document findings. However, taking time to document correctly and completely provides the first line of defense should you be named in a lawsuit.

Do’s and don’ts of defensive documentation in the EHR

This is sponsored content provided by Nurses Service Organization (NSO). Through AORN’s partnership with NSO, AORN members can save 10% on nurses’ malpractice insurance for three consecutive years with NSO’s Risk Management Discount. Receive a quick quote today.

Documenting care is a basic nursing responsibility, but it’s one that nurses often struggle with because of time constraints and challenges associated with electronic health records (EHRs), such as poor user interfaces that leave nurses unclear as to where to document findings. However, taking time to document correctly and completely provides the first line of defense should you be named in a lawsuit.

Nurse Practitioner License Protection Case Study: Failure to document medication management in EHR

A State Board of Nursing (SBON) complaint may be filed against a nurse practitioner (NP) by a patient, a patient’s family member, colleague, employer, and/or other regulatory agency, such as the Department of Health. Complaints are subsequently investigated by the SBON to ensure that licensed nursing professionals are practicing safely, professionally, and ethically. SBON investigations may lead to outcomes ranging from no action against the NP to revocation of the NP’s license to practice. Therefore, when a complaint is asserted against an NP to the SBON, NPs must be equipped with the resources to adequately defend themselves. Being unprepared may represent the difference between an NP retaining or losing one’s license. This case study involves a psychiatric mental health nurse practitioner (PMH-NP) who was working in an outpatient psychiatry practice.

What to Do in an Active Shooter Situation

Does your workplace have a plan in place for how to handle an active shooter? Would you know how to react to protect yourself and your patients or clients?

Reducing readmissions through discharge communication

One of the most important transitions in the continuum of care is patient discharge. Unfortunately, many patients across the country will leave hospitals, clinics, and healthcare provider offices unsure about what medications to take, when to make a follow-up appointment, and other critical details about their care.

Nurse Practitioner License Protection Case Study: Failure to document medication management in EHR

This is sponsored content provided by Nurses Service Organization (NSO). Through AORN’s partnership with NSO, AORN members can save 10% on nurses’ malpractice insurance for three consecutive years with NSO’s Risk Management Discount. Receive a quick quote today.

Create effective anti-bullying policies

Workplace bullying contributes to decreased team cohesion, burnout, retention issues, and absenteeism. This article will help managers and other nurses influence policy development with suggestions on crafting usable and effective anti-bullying policies.

Protect Your Professional License, Protect Your Livelihood

When you purchase your own professional liability insurance policy through Nurses Service Organization (NSO), you have peace of mind knowing that you have the resources available to protect your license and your right to practice.

Overcoming the pitfalls of medication reconciliation

Any time there’s a hand-off in patient care, there’s an increased risk for a medication error. Medication reconciliation has been used to help bridge this hand-off communication on admission, between transfers in the hospital, and at discharge.

When to Refuse a Nursing Assignment

Being assigned to an unfamiliar clinical area is one thing, but what if you are ordered to perform an unfamiliar procedure or a task that’s outside the scope of nursing practice? When should you refuse an assignment?

End of Life Care: Responsibilities and Risks

Nurses can make a major contribution in easing the transition from aggressive treatment to palliative care, regardless of the setting. To do so, they must be prepared to make ethical and humane decisions while also avoiding professional liability exposures.

The Ins and Outs of Patient Abandonment

What is patient abandonment, and why do nursing students need to know about it? 

Social Media Etiquette for Nursing Professionals

Social media is a powerful tool that almost everyone uses, but it’s important to remember that what’s shared on social media can have negative effects on your life and career.   

Do Not Let “Depo-” Medications Be a Depot for Mistakes

NSO and the Institute for Safe Medication Practices (ISMP) have teamed up to help you practice safe medication use and keep patients safe. The following is an ISMP Medication Safety Alert from the May 2017 NSO Risk Advisor.

Nurse Practitioner Case Study: Narcotic medications prescribed to patient when not medically indicated

This case involves two insured nurse practitioners who owned a primary care medical clinic.

Dispensing Alert! Dial, Set, and Lock that Dose

NSO and the Institute for Safe Medication Practices (ISMP) have teamed up to help you practice safe medication use and keep patients safe. The following is an ISMP Medication Safety Alert from the August 2017 NSO Risk Advisor.

Hospital Workplace Violence and Safety Response

Healthcare workers, and in particular hospital workers, are at high risk for workplace violence. Yet many hospitals don’t have safety protocols in place, and those that do often haven’t examined protocol adherence or efficacy.

Nurse Practitioner Case Study: Failure to warn patient of dangers of testosterone treatment

This case study involves a Family Nurse Practitioner (FNP) who owned an adult wellness clinic, which specialized in hormone replacement for both male and female patients, as well as weight management. The FNP employed the collaborating physician, an OB/GYN, front office staff and two licensed practical nurses.

Nurse Practitioner Case Study: Untimely management of a behavioral health patient and failure to order the appropriate medication

This case study involves a psychiatric mental health nurse practitioner (PMHNP) insured by NSO who was employed at a behavioral health/detoxification facility (“facility”).

Are You Filing Incident Reports Properly?

Knowing when—and how—to file incident reports can help you to protect yourself, your patients, your colleagues, and your organization.   

Nurse Case Study: ICU Charge Nurse allegedly failed to monitor a critical patient and escalate treatment

Medical malpractice claims may be asserted against any healthcare practitioner, including nurses. This case involves a registered nurse working in the Intensive Care Unit (ICU) as a Charge Nurse.

Keeping up with technology: your risks and responsibilities.

Information technology is constantly evolving. Among the most common types are electronic health records (EHRs) and computerized physician order entry systems (CPOEs).

Keeping up with technology: your risks and responsibilities.

Information technology is constantly evolving. Among the most common types are electronic health records (EHRs) and computerized physician order entry systems (CPOEs).

Do's and Don'ts of Documentation

Good documentation can help nurses defend themselves in a malpractice lawsuit, and keep them out of court in the first place. 

Don't cross the line: respecting professional boundaries.

At best, nurses and patients develop a special bond based on trust, compassion, and mutual respect.

Documentation: proactive prevention of litigation.

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

Documentation on trial: 9 ways to protect your agency.

In most states, a patient can wait several years to file a lawsuit and then it can take years before the suit goes to court.

Defensive Documentation: Steps Nurses Can Take to Improve Their Charting and Reduce Their Liability

Whether you are an experienced nurse or recent grad, documentation can be challenging. Here is some information that can assist with improving your charting and reducing liability risks:  

Charting by exception: the legal risks.

There are numerous variations to charting by exception. Virtually every facility that uses such a system does it differently.

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.

Administer meds without a doctor's order? Proceed with caution.

Registered nurses generally should administer medications only with a physician’s order. Only certain advanced practice nurses have prescriptive authority, and their qualifications, as well as the type of drug and the amount they are allowed to prescribe, vary from state to state.

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.

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.

Creating Inclusiveness for Transgender Patients

As a nursing professional, being attuned to the needs of transgender patients helps you ensure their health needs are met and reduces the risk of legal liability.

Nurse Case Study: Alleged failure to assess and monitor teen patient’s pulmonary status

A male patient in his mid-teens arrived at his pediatrician at 5:11 p.m. with complaints of difficulty breathing.

Nurse Practitioner Case Study: Family NP allegedly failed to assess and monitor patient, resulting in death

A female in her late 70s was a long-term patient of our insured nurse practitioner (NP) and of the family practice where the NP worked.

Nurse Leader Case Study: Failure to perform appropriate hiring practices

Medical malpractice claims may be asserted against any healthcare practitioner, including nurses. This case involves a registered nurse working as a director of nursing in a rehabilitation/skilled nursing facility setting.

Nurse Leader Case Study: Failure to perform Director of Nursing duties in a competent manner

A State Board of Nursing (SBON) complaint can be filed against a nurse by a patient, resident, colleague, employer, and/or regulatory agency.

Educator Material Request Form​​​

NSO has developed an Educator Program to make it easy to receive case studies, articles and claim reports to use in your classroom. Sign up to join our educator program below!

Nurse Practitioner Case Study: Failure to counsel patient on risks of noncompliance

This case involves a family nurse practitioner (NP), her business (a women’s health clinic), and employees that specialized in gynecology and hormone therapy.

Educator Toolkit: Communication for Nursing Professionals

Clear, effective communication is vital for a nursing professional, especially when it involves patients, families, coworkers, supervisors and others. In this section, you can help improve your students' awareness of the critical nature of verbal and non-verbal communication, with particular emphasis on hand-offs, chain of command, disclosure, treatment, social media and more.

Nurses’ Malpractice Insurance Claim Reports

Ever wonder why nurses are sued for malpractice and what you can do to reduce the risk of a potential lawsuit? Now you can find out. NSO, in collaboration with CNA, has released their new report: Nurse Professional Liability Exposure Claim Report: 4^th Edition: Minimizing Risk, Achieving Excellence.

Educator Toolkit: Documentation for Advanced Practice Nurses

Help raise your students' awareness of documentation risks that can lead to claims of negligence and malpractice, and show them that by improving the quality of documentation, they can see fewer malpractice incidents.

Nurse Practitioner Claim Report: 4th Edition - A Guide to Identifying and Addressing Professional Liability Exposures

This Nurse Practitioner Claim Report released by NSO and CNA, reports that the average cost to defend a malpractice lawsuit against a nurse practitioner is $60,034.   

Educator Toolkit: Documentation for Nurses 

Accurate documentation is a critical component of patient care. With materials in this section, you can help raise your students' awareness of documentation risks that can lead to claims of negligence and malpractice, and that by improving the quality of documentation, they can see fewer malpractice incidents.

Nurse Practitioner Professional Liability Exposure Claim Report: 5th Edition

This Nurse Practitioner Claim Report, released by NSO and CNA, reports that the average total incurred of professional liability claims is $332,137 in 2022. 

Learn about malpractice prevention and earn CE credits.

"Focus on Malpractice Prevention" is a risk management continuing education program that offers CE accreditation and a 10% discount on NSO premiums.