What is technical writing?
Technical writing is the ability to explain complicated concepts or processes in understandable terms. It relies on knowing your purpose, your audience, and how much knowledge your readers may have on the topic. A nurse's charting should be factual, accurate, concise, complete, and current.
Legal Implications
A nurse's documentation may be read by lawyers and experts if a law suit arises. Every detail in the medical record is examined by expert nurses and lawyers to make a case for their side. They are looking for reasons as to what went wrong. A nurse's goal is to provide factual, accurate, concise, complete and current charting about patient care.
Situation:
An unconscious patient is admitted to the ER after a MVA. The patient has lost a lot of blood due to traumatic injuries. They require a blood transfusion and fluids to prevent going into hypovolemic (shock from not enough blood/fluid in the circulation system) shock. The nurse is unable to contact any family members to get consent for the blood transfusion. The patient is still unconscious. The hospital’s policy states that in emergency situations blood, or surgery may be given/performed without consent if there is a threat of losing life without the treatment. The nurse begins administering the blood. As a result of the blood transfusion, the patient has an anaphylactic reaction and dies. It is later learned the patient is a Jehovah's Witness whose religion prohibits the use of blood products. The family is now wanting to sue for what they believe is malpractice. How could the nurse have charted to prove that the patient needed the blood, tried to get ahold of the patient’s family multiple times without success, and that the blood was needed to sustain life?
What NOT to do:
“Patient is bleeding from traumatic injury to head, stomach, and leg. Patient needs blood transfusion. Patient is unconscious. Unable to reach family. Patient is unconscious. Will infuse blood per MD order.”
What to do:
“Patient is bleeding from traumatic injuries to head, stomach, and leg. Patient’s Hemoglobin (normal levels of Hemoglobin vary depending on age or sex. Usually blood will be transfused if below 8.0) is 4.9 per labs drawn on patient’s arrival to ER. Blood pressure is 72/30 and HR is 146 (signs of hypovolemic shock, or low volume). Oxygen saturation 92% with Venti Mask on. Patient with NS (normal saline) bolus infusing currently, but needs blood transfusion per MD orders to replace blood loss and to continue to bring up and maintain blood pressure. Attempted to notify family x 5 for consent for blood. No answer. Per Dr. Smith patient needs blood to sustain volume and organ function.
Be sure to be actual, factual, accurate, concise, complete, and current in your charting to protect yourself, and your license! Remember if it was not charted it was not done.
Tips on Charting Legally
In the "What Not to do" scenario, it states pt needs blood transfusion. It states unable to reach family. In court it may be asked why was family needed to be reached or how many times did the nurse attempt to reach the family.
Per mcandl.com/arkansas.html , the statute of limitations for medical malpractice cases in Arkansas is two years. The claim "must be brought within two years after the date of the wrongful act complained of." Two years is a long time for a nurse. You may take care of hundreds or thousands of patients depending on your job within that time frame. Always remember to make sure you will remember your patients from your charting if you are called to court in two years.
McCullough, Campbell, and Lane LLP; mcandl.com/arkansas.html; "Arkansas Medical Malpractice Summary" 2011; Web; accessed 27 Nov 2014.
Technical writing is the ability to explain complicated concepts or processes in understandable terms. It relies on knowing your purpose, your audience, and how much knowledge your readers may have on the topic. A nurse's charting should be factual, accurate, concise, complete, and current.
Legal Implications
A nurse's documentation may be read by lawyers and experts if a law suit arises. Every detail in the medical record is examined by expert nurses and lawyers to make a case for their side. They are looking for reasons as to what went wrong. A nurse's goal is to provide factual, accurate, concise, complete and current charting about patient care.
Situation:
An unconscious patient is admitted to the ER after a MVA. The patient has lost a lot of blood due to traumatic injuries. They require a blood transfusion and fluids to prevent going into hypovolemic (shock from not enough blood/fluid in the circulation system) shock. The nurse is unable to contact any family members to get consent for the blood transfusion. The patient is still unconscious. The hospital’s policy states that in emergency situations blood, or surgery may be given/performed without consent if there is a threat of losing life without the treatment. The nurse begins administering the blood. As a result of the blood transfusion, the patient has an anaphylactic reaction and dies. It is later learned the patient is a Jehovah's Witness whose religion prohibits the use of blood products. The family is now wanting to sue for what they believe is malpractice. How could the nurse have charted to prove that the patient needed the blood, tried to get ahold of the patient’s family multiple times without success, and that the blood was needed to sustain life?
What NOT to do:
“Patient is bleeding from traumatic injury to head, stomach, and leg. Patient needs blood transfusion. Patient is unconscious. Unable to reach family. Patient is unconscious. Will infuse blood per MD order.”
What to do:
“Patient is bleeding from traumatic injuries to head, stomach, and leg. Patient’s Hemoglobin (normal levels of Hemoglobin vary depending on age or sex. Usually blood will be transfused if below 8.0) is 4.9 per labs drawn on patient’s arrival to ER. Blood pressure is 72/30 and HR is 146 (signs of hypovolemic shock, or low volume). Oxygen saturation 92% with Venti Mask on. Patient with NS (normal saline) bolus infusing currently, but needs blood transfusion per MD orders to replace blood loss and to continue to bring up and maintain blood pressure. Attempted to notify family x 5 for consent for blood. No answer. Per Dr. Smith patient needs blood to sustain volume and organ function.
Be sure to be actual, factual, accurate, concise, complete, and current in your charting to protect yourself, and your license! Remember if it was not charted it was not done.
Tips on Charting Legally
In the "What Not to do" scenario, it states pt needs blood transfusion. It states unable to reach family. In court it may be asked why was family needed to be reached or how many times did the nurse attempt to reach the family.
- Be accurate with your charting. State how and why family was attempted to be reached.
- Give a clear accurate assessment that will not leave the reader wondering why something was or was not done.
- Be sure to chart any supporting information such as blood pressure, labs, and full assessment of patients condition to support why what was done was done or not done.
Per mcandl.com/arkansas.html , the statute of limitations for medical malpractice cases in Arkansas is two years. The claim "must be brought within two years after the date of the wrongful act complained of." Two years is a long time for a nurse. You may take care of hundreds or thousands of patients depending on your job within that time frame. Always remember to make sure you will remember your patients from your charting if you are called to court in two years.
McCullough, Campbell, and Lane LLP; mcandl.com/arkansas.html; "Arkansas Medical Malpractice Summary" 2011; Web; accessed 27 Nov 2014.
Definition for Technical writing from: Macelemale, Laura; classroom.synonym.com/impoirtance-technical-writing-nursing-students-1265.html; “Importance of Technical Writing in Nursing
Students.” Web; accessed 8 Nov
2014.
Picture from: Ward, Jennifer; http://www.nursetogether.com/soapie-effective-nursing-documentation; “SOAPIE: Effective Means to Good Nursing Documentation” 17 Oct 2014; Web; accessed 8 Nov 2014.
Picture from: Ward, Jennifer; http://www.nursetogether.com/soapie-effective-nursing-documentation; “SOAPIE: Effective Means to Good Nursing Documentation” 17 Oct 2014; Web; accessed 8 Nov 2014.