Nursing Malpractice: Liability and Risk Management

By Charles C. Sharpe | Go to book overview

10

The Medical Record As Evidence
in Nursing Malpractice

THE MEDICAL RECORD
The medical record, in its entirety, is a written chronicle of the medical and nursing care that a patient has received, or is expected to receive, over a period of time, and a record of those who provided that care. This includes care prior to admission to an institution, care while in the institution, or an anticipated course of treatment after discharge. It is first and foremost a medical document and second a legal document. As a legal document it will provide evidence of the type and quality of care that a patient received at the hands of those caregivers whose orders, progress notes, and various reports are included in it (Sharpe 1999).
Standards and Purposes of the Medical Record
In the Accreditation Manual for Hospitals, the JCAHO defines the standards and purposes of a medical record. These are applicable in all patient care settings.
Standards
The record will confirm that the patient has been properly identified, assessed, and admitted to the institution

-105-

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