The entries made by a professional nurse in the patient’s clinical record are recognized as testimony in the courtroom. The complete medical record is identified as evidence in the courtroom. The plaintiff and defense counsel will use any document they wish to help tell their interpretation of the facts of the case to the jury. The nursing entries are valued for the immense patient information they contain. The nurse is the one who is with the patient 24 hours a day, coordinating the care and activities of all disciplines. These functions are multifaceted and can range from diagnostic or clinical testing to therapeutic interventions.

What is the role of documentation in nursing care? It is more than simply writing a note every shift or updating a plan of care at regular, defined intervals. Documentation is written communication between members of the healthcare team. Verbal and nonverbal communication is not captured in the medical record unless it is recorded or documented. If the verbal and nonverbal communications are not recorded, the result is, all is forgotten. The remembering and making entries about what care occurred, including patient responses, and myriad other details, now, take on a whole new meaning with greater importance in the clinical record.

The medical record is your best defense should your care come into question and under scrutiny. If malpractice or negligence is alleged, your entries in the medical record, along with your fellow peers, will most likely determine the outcome of the case. The documentation is heavily relied upon for the very reason as defined above, the documentation, is the evidence of the facts. The medical record is the only source of written communication, for all members of the healthcare team. Each member of the healthcare team contributes patient care according to their specialty and records the care provided including any and all assessments, interventions and outcomes. The actual recording of the events must be recorded as close to the timing of the events as possible.

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