Would Your Documentation Hold Up In Court?

In this hurry up paced work environment most nurses find themselves in, it is easy to see how certain tasks may get shortchanged in an effort for efficiency. Everyone is pressed for time- yet there are specific tasks nurses must do each shift and do quickly.

One area that should never be shortchanged is documentation. “If you didn’t document it, you didn’t do it.” How many times have you heard that? This is true and your documentation will not hold up in court if you have sloppy documentation.

Mr. Jones has a decubitus (pressure injury) on his coccyx. Two different nurses on different shifts document in his chart regarding this wound. Which one would hold up in court? Who would you rather follow?

10/02/2017   “Pt. has a quarter-sized pressure sore on his coccyx. Area was cleaned and redressed. Pt is a little uncomfortable. Repositioned.”


10/02/2017 0820 “Pt has a decubitus on his coccyx measuring 3.0cm x 1.8cm x 0.3cm.  30% red granulation tissue, 70% yellow slough with moderate amounts of serosanguinous drainage noted. Area cleansed with NS and wound dressed with Santyl, gauze and bordered foam. Pt repositioned on his L side. Pt c/o pain 3/10, Tylenol offered and given.

  • Always measure your wounds L x W x D and use the clock as your guide. Head =12 o’clock, Feet =6 o’clock.
  • Describe your findings, otherwise, no one will know what you saw or if the wound looks worse or better than last time.
  • Date and time all entries.
  • Include how you personally are keeping pressure off the wound.