Defensive charting is one of the best ways to protect any health care provider from exposure to legal liability. Chart with a jury in mind! Careful and complete documentation of nurses' progress notes is a principal method of reducing the risk of liability in nursing malpractice lawsuits. They may sustain or preclude a suit for negligence from the outset. They may support or undermine the nurse-defendant before a jury in the event of a trial. In a negligence suit, nursing documentation will be as critical a factor as the nursing care itself. A nurse's notes should provide answers to questions at issue in a lawsuit. They should not prompt more questions or raise additional issues. Poorly written notes can be a veritable gold mine for the patient-plaintiff's attorney.
The presumption in law may be that if an event is not documented, it did not take place, and if it is not written in the record, the nurse did not do it (or even consider doing it). The maxim familiar to every student nurse and practicing nurse is: [If it was not charted, it was not done.] This is frequently a contentious issue in malpractice litigation. It is a misconception that should be rejected as unrealistic—as an unattainable performance or unrea