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From a legal aspect, could our agency or an RN have problems if the exact dosing and frequency of medication is not included in the clinical notes?

Wednesday January 2, 2013
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Dear Nancy,

I am an intake RN at a home health agency and I receive various orders from physicians for medications, such as Coumadin. To document this, I write the orders in our computer system under a separate tab for orders (versus clinical notes). Then I write a clinical note stating, "Relayed Coumadin orders to patient and he verbalized his understanding and repeated the correct dosing and frequency. VM to Susie Nurse to repeat protime/INR in one week." Is that sufficient? Or do I need to write “Relayed Coumadin orders to patient. He verbalized his understanding and repeated correct dosing and frequency of Coumadin 2mg PO HS. VM to Susie nurse to repeat protime/INR in one week, 6/30/11." The difference is time consuming, since I have already written the orders, but some in our office believe it is critical to write the actual dosing and frequency that was relayed to the patient. From a survey or legal aspect, could our agency or the RN be reprimanded on a review or have trouble in court if the exact dosing and frequency is not rewritten in the clinical notes?


Nancy Brent replies:

Dear Kaelyn,

From a legal perspective, the more detailed a nurse's note, the better. Although this general rule of thumb does sometimes result in repetitive documentation, it may help a nurse and/or a facility if there is a patient injury or death. This is especially true when doing family or patient teaching.

Using your two entries as examples, the first entry could be open to challenge because it is more vague than the second entry, which specifically records what was said to the patient. Since there is a general presumption that a nurse does not falsify nursing notations in the record, the specificity of what is documented must be successfully challenged by someone doing so (e.g., a patient, a family member). Although the general presumption that the nursing notation is not falsified, that presumption can be rebutted by evidence to the contrary, if it exists (e.g., a witness to the teaching about the medication).

Documenting what was said to a patient or a family member need not always be in narrative form. Teaching forms or checklists, if properly developed, can take the place of a narrative entry, are legally sound and stand as being truthful — unless someone successfully challenges its veracity.

Some resources you might want to check to help you with this issue are:
• Whitehouse (1979), "Forms that Facilitate Patient Teaching," 79(7) American Journal of Nursing, 1227-1229
• “The Complete Guide To Documentation.” 2nd Edition. Lippincott Williams & Wilkins, 2008
• Alspaugh, "A Guide for Nurses: Teaching Healthcare Effectively to Patients," Healthcare Careers Journal. Available at www.healthcareersjournal.com/a-guide-for-nurses-teaching-healthcare-effectively-to-patients.


Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.