In Nursing Standard of Care Guidelines: Why a blank or incomplete medical record suggests conduct that falls below the standard of care, attorney Kristin Miller answers the question “Why does a blank or incomplete medical record indicate a likelihood of nursing conduct that falls below the standard of care?”
“Nurses are required to routinely conduct assessments and reassessments, and they are required to document all of their findings in the patient’s medical record. A blank or sparsely filled in medical record at a time when the patient is receiving intensive care is a strong indicator of below standard conduct by the nursing staff.” Says Gayle Nash with Nash Legal Nurse Consulting, and a Chief Nursing Officer with twenty-seven years of executive nursing leadership experience.
A myriad of patient care considerations go into each patient assessment and reassessment. Nash preaches that a skilled nurse performing their work pursuant to standard of care will practice due diligence in their charting practices thoroughly performing as well as documenting each assessment and reassessment. The medical record, after all, is the patient care fingerprint indicating both the patient’s health status as well as how the nurses are performing and completing their patient rounds. A sparsely complete medical record should be investigated as a possible indicator of below standard nursing conduct.