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Not Documented, Not Done...

Not Necessarily!

We've all had it drilled into us by our nursing instructors and risk managers. "If it wasn't documented, it wasn't done". The problem with this statement? It's not necessarily true. And, as a legal nurse consultant, you need to know the facts.

You see, evidence consists of both written documentation (such as that found in medical records) and sworn testimony (such as that provided by the plaintiff and healthcare providers in depositions and at trial).  So if the medical record says one thing and a healthcare provider refutes what's in the medical record, it's up to a jury to determine which version of the story is believable.

Granted, a jury might put more weight on medical records that were written contemporaneously as the events unfolded than they might on a healthcare provider's recollection of the facts. But juries decide cases based on their understanding and beliefs related to ALL the evidence, not just medical records.

Doesn't lack of documentation violate a standard? Yes and no. Let's say that a nurse turned a patient every two hours but didn't document it.  The nurse probably violated a documentation standard (because he or she didn't record that the patient was turned) but not a hands-on patient care standard (because the patient was indeed turned).

But what about proof? If healthcare providers don't document something, how can they prove that it was actually done? They prove it through their sworn testimony because sworn testimony IS proof.

If you work independently or as an expert for the plaintiff and review medical records, you'll likely continue to work on the "not documented, not done" principle by emphasizing every instance of lack of documentation and extrapolating the lack of documentation as lack of patient care. If you work for the defense and documentation is lacking, you'll speak with the healthcare providers to determine their recollection of events. Sometimes nursing staff members remember the patient and remember providing care but are so intimidated by their "not documented, not done" training that they actually believe that the care they remember doesn't count! If that's the case, you'll need to reassure them and explain documentation versus patient care standards.

Thorough, factual, and complete documentation has no doubt prevented many lawsuits. But the catch phrase "not documented, not done" is not necessarily accurate. Maybe it's time for a different catch phrase?

..Katy Jones






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