Minimizing Legal Liability Through Effective Record Keeping

By:Mr. M.Shivananda Reddy

As the records are the proof of care and legal documents the records have to be maintained appropriately to avoid legal complications.

The nurse has to take the following measures:• Keep the records under safe custody of nurses.• No individual sheet should be separated.• Maintain the confidentiality of the information• Don’t make accessible to other patients and

visitors.

• Strangers are not permitted to read records.• Records are not handed over to the legal advisors

without written permission of the administration.• Handed carefully, not destroyed• Identified with bio-data of the patients such as

name , age, admission number, diagnosis, etc. • Never sent outside of the hospital without the

written administrative permission.• Send the records to medical record department

(MRD) for the further usage

• YOU SPILL SOMETHING ON THE CHART, DO NOT DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED SHEETS IN CHART. WRITE “COPIED” ON COPY.

• DO NOT SCRIBBLE OUT CHARTING.

• FOLLOW YOUR FACILITIES POLICY.

• DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.

The documentation in the records has to be made by following the principles of recording like:

• Date & time• Timing• Legibility• Permanence• Correct spelling• Signature• Accuracy• Sequence• Appropriateness• Completeness• Conciseness• Accepted terminology

Maintenance Of Computerized Records:

• Maintain the confidentiality of the information.• Never disclose the password to any others • Don’t delete any information from the system

unless you are authorized to do.