Refrain From Making Negative Comments

Bet you wondered how you were supposed to document everything but refrain from entering negative comments about the patient in the medical record.

If a patient is noncompliant please document that but avoid mentioning things like the patient's personality and even body odor. The plaintiff's attorney will use these negative comments to suggest you disliked the patient and were more likely to provide substandard care.

Stein, T. (2000). More patients are naming nurses in malpractice suits. Retrieved from http://www.nurseweek.com/features/00-05/malpract.html