Documentation: Avoiding the Pitfalls

LNC.tips/docume... Why do patients sue for malpractice? What is the role of the medical record in how legal cases are screened for merit? How should health care providers address delay in treatment & failure to rescue patients? Why it is so important to have legible orders? Pat Iyer answers these questions and more based on her 28 years of experience as an expert witness and expert in nursing malpractice.

[@ThomasStroble-MIInjuryLawyers]

Having clear and legible notes is a good start. A honest and open dialogue between the patient and their family is another big step that can clear up a lot of confusion.

[@trishschmidt8530]

I think all prescriptions should be typed in! No more dr. chicken scratch!

[@treasirewealth4024]

I do Bull writing-

[@annjean8709]

Absolutely!👏🏾👏🏾👏🏾

[@trishschmidt8530]

People who do not report mishaps (like dropping a person from a hoyer lift) are cowards! Plain and simple! If you made a mistake you need to be responsible and make it right! Own up to it like an adult! It is called integrity.

[@johnpuleo3176]

It's called being stupid !!

[@brownricegirl]

Could have said more, especially to the effect of computer charting. Are there any pitfalls in computer charting? Might it cause a false sense of protection? Might it back fire? Candid commentary from the nurse audience would have been interesting. Thank you for posting.

[@marthitahuezo7641]

It is of most importance to ask questions when there is a need for clarification, doesn’t matter if we have for A second time or if the doctor feel a nurse or a nurse assistant is bothering, A person medical treatment is not a matter that can be responsibly done if a care team member assumed they understand when they did not.
Handwriting clearly is caring. If a person does not know how to write, they should practice more or taje their time to write at least clearly.
Name medications and dosage fir each patient is different. Please double check before providing. If you notice a change, please double check and ask your supervisor.
If you receive information from family members about something that can be important for treatment, let nurse know.

[@thadtayo]

Thanks for sharing! This is a very important issue...hope you'll post more.

[@Ladyandapies]

When you call a doc at home for order clarification they yell at the RN and make them to feel like an uneducated fool. Theyre so arrogant and feel the nurse is a piece of dirt! I overheard one doctor tell another that the nurse and nurse assistant have the same level of education! What an insult! Why should a nurse get yelled at and belittled for asking a doc to clarify his sorry chicken handwriting to prevent med errors? They should read the bible & see what God says about arrogance!

[@wehttamak]

nurses need to stand up to that type of abuse im presently a nursing student certain things i am not going to tolerate no dr and i repeat no dr will make me feel less than a person

[@Purplecolors88]

Most Dr are assholes they not all smart

[@naomilaboo]

Nicely done!

[@0326hkim]

freakin doctors need to slow down a little and focus on their writing. i hate their chicken scratch writing.

[@jcnoel1777]

0326hkim lol😂😂😂

[@biancahinojosa2778]

She said toradol and then said demerol?.......

[@sandyingold2010]

Very informative

[@sonofnok2153]

You know can't challenge the ALMIGHTY doctors. How dare you, when they studied it for 15yrs, and you the nurse just studied it for 4yrs?

[@kubu79]

204 mg?? that is a huge lot!

[@angelahk28f]

So you decide not to call the doctor and just guess? Perhaps you can contact a different onsite doctor for a second opinion.....