The ethical dilemma scenario was the perfect Segway into the second topic, defensible medical record documentation. Emphasis was placed on the 6 principles of medical record documentation put forth by the ANA:
- "DOCUMENTAION CHARACTERISTICS - accessible, accurate, relevant, consistent, auditable, clear, concise and complete, legible, and thoughtful/factual
- EDUCATION AND TRAINING" - studies show that there is still room for improvement in documenting patient care according to the nursing process
- "POLICIES AND PROCEDURES - dictate the standard against which nursing practice is judged in disciplinary proceedings and in the court of law
- PROTECTION SYSTEMS - log off computer when moving away from the terminal
- DOCUMENTATION ENTRY COMPONENTS - must be accurate, valid, complete, authenticated (truthful), dated and timed, legible, and with use of standard terminology
- STANDARDIZED TERMINOLOGIES"
Throughout the presentation Marcelle injected her experience having assisted with medical - legal case development in the capacity of a "behind the scenes" legal nurse consultant and testifying expert consultant, furthering the vital concept of ethical nursing practice and defensible documentation. Examples of sound documentation versus poor documentation highlighting their advantages and disadvantages in litigation were presented and discussed as well. In all, the students came away with the tools needed to build their nursing practice on solid ethical ground while incorporating defensible documentation, professional accountability, and a greater sense of personal integrity, thereby increasing their ability to defend their nursing practice in litigation.