Legal Issues in Documentation

Chapter 6: Legal Issues in Documentation

Overview:

• Discusses specific legal principles relating to the provision of medical and nursing care
• Explains the processes when nursing records are called into question
• Points out the advantages of keeping records updated

Description:

At no point can you afford to be careless in your attitude towards documenting nursing care. Inadequate records may give the client’s account of the circumstances surrounding the care more credence than your hazy recollection. In this chapter, learn about the importance of contemporaneous record keeping, about the legal complications of poor documentation and more.

Topics:

• Principles Of Legally Correct Documentation
• When Nursing Records Are Called Into Question
  • Civil Suits
  • Coronial Inquiry
• The Value Of Well-Kept, Contemporaneous Records
  • The Legal Consequences Of Poor Documentation
• In Summary
• Suggested Reading

Speaker/ Author:

Audrey Jamieson RN, BA, LLB
Audrey commenced her general nurse training at the Alfred Hospital, Melbourne, in 1974, becoming a registered nurse in 1977. In 1980 she completed the Alfred’s cardio-thoracic intensive care course and consolidated her cardiac nurse training by working in the cardio-thoracic and coronary care units. In 1984 Audrey commenced undergraduate studies at Monash University, first in arts, adding law a year later, and completing her BA, LLB in 1988. Audrey continued working as a nurse until early 1989 when she commenced article clerkship. She was admitted to the Victorian Supreme Court Roll as a barrister and solicitor in 1990.

Today Audrey is an associate partner in the firm Maurice Blackburn & Co in Carlton, Victoria, and works a busy personal injuries practice. She is an accredited personal injuries specialist with the Law Institute of Victoria and is the current secretary of the Australian Association of Nurse Lawyers. Audrey speaks regularly to groups of nurses on duty of care issues, including monthly addresses to the graduate nurse program at the Alfred (where she just can’t seem to cut that cord!).

Professional Reviews: