Sage-Tips

Are medical notes legal documents?

Health professionals also find good medical records vital for defending a complaint or clinical negligence claim, given the insight that they provide into the clinical judgment that was exercised at the time. In general, if records are adequate enough for continuity of care, they will also suffice for legal use.

What are your legal obligations when it comes to documentation and using clinical case files?

The patient’s records should:

• Be factual, consistent and accurate;
• Be updated as soon as possible after any recordable event;
• Provide current information on the care and condition of the patient;
• Be documented clearly in such a way that the text cannot be erased;

What is false documentation in nursing?

Falsification of nursing documentation; unprofessional conduct likely to deceive, defraud or harm the public; and not meeting standards of nursing practice are examples of grounds upon which the board could allege against the nurse managers.

Can medical records be amended?

However, medical records may sometimes need to be amended. Any change should be clearly documented either electronically or in writing to show the date of the amendment and the name of the individual making the change – in other words that there is an identifiable audit trail.

Is nursing documentation a legal document?

Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice.

What should be included in nursing documentation?

The nursing record should include assessment, planning, implementation, and evaluation of care. Ensure the record begins with an identification sheet. This contains the patient’s personal data: name, age, address, next of kin, carer, and so on. All continuation sheets must show the full name of the patient.

Are nurses allowed to give medical advice?

It is the nurses’ responsibility to provide information and to therapeutically communicate with the patient so that the patient can make informed decisions with his primary care provider, family, etc. If I have a pt that is asking for advice, what they are looking for is usually information.

Is it a crime to impersonate a nurse?

You might not know it but impersonating a nurse is a crime. And even though a medical assistant may believe what they are doing is innocent, in reality it is a crime.

https://www.youtube.com/watch?v=9u53jNI4qoU