As a nurse who has experience working in the busiest, most intense ICU in the hospital, I know firsthand how this area could be considered high-risk. ICU’s aren’t the only areas considered high-risk. I believe anything that can go by initials (ER, OR, L&D) can be high risk as well. This is not to say that nurses on medical surgical floors are not exposed to legal risk, it just goes to say that nurses in specialized units are expected to perform more specialized procedures. With the expectation of nurses performing tasks that once only doctors did, the responsibility on these units gives increased liability.
Today’s nurses have to deal with more complex medicine, high-tech equipment, and very, very sick patients who require close monitoring. Other factors that contribute to liability for nurses in these areas include; high nurse-to-patient ratios, limited staffing, and demanding family members to name a few.
Why are demanding family members and patients more prone to suing? When the patient or family members perceive improper care or lack of care by the hospital they tend to blame the front-line person…the nurse. This is because a nurse is with the patient 24-7. Nurses are ever-present doing hands-on patient care. This prominent factor is one of the reasons nurses in these specialized units are sued more often.
It is important for nurses to protect their licenses at all times. Protection of your license includes being prudent with your nursing care, carrying professional liability insurance, and proper documentation. Documentation not only includes the medical record, but personal documentation as well.
I like to call personal documentation C.Y.A. (“Cover You Ass” or better yet, “Cover Your Assets”).
During my career I have participated in C.Y.A. charting on more than a few occasions.Legal experts suggest that this charting is not done on company computers, because it can “magically” disappear when you need it. I would suggest having a notebook and writing information down as needed and place it in a safe place at home or rewrite on your own personal computer.
C.Y.A. charting may be used when you are having a particular busy day and feel like a problem may arise because of it. It can also be employed when you have patients or family members upset about the care they have received or perceived they have received. Write down as much information you can without compromising HIPAA of those involved. For instance, use the patients’ initials and medical record number so employers and the court of law will know who the entry is in regard to.
Do not show these documents or reveal that you keep records to anyone unless you are in a situation in which you need to! These situations include but are not limited to being called in to your manager’s office for a potential problem or being named in a lawsuit. I wouldn’t even tell anyone that you have kept records such as these. Any information you give to anyone can be used against you in a court of law!