Category archives for Documentation


The nursing assessment is an important tool not only for the nurse performing the assessment but as I tool to determine progress or lack of progress of a patient.  As a Legal Nurse Consultant reviewing the nursing record of a patient you also need to determine the accuracy of the assessments.  One might suggest that […]

A Picture is Worth 1000 Words

I have had the opportunity recently to review two cases involving significant injuries stemming from an IV infiltration.  Both of these cases involved medications infusing peripherally that if at all possible should have been infusing via central access.  The documentation with both of these cases was also very confusing.  Some infusions did not have the […]

Nursing Documentation: Legal Ramifications

Nursing Documentation:  Legal Ramifications My experience as a clinical bedside nurse and a legal nurse consultant has proven to me that many nurses simply do not understand the medical and legal ramifications of poor, incomplete documentation.  Yes, the medical record is a document that, if not properly utilized, can lead to problems for the healthcare […]