“No distress noted.” What a court asks about a conclusion without findings
Exhibit 9 a quick look
No distress noted.
Noted how? It records what you concluded, not what you saw: breathing, color, what the patient said. It also says nothing about whether the care that was due got done.
What they ask about it
The plaintiff's expert, reading only the nurse's notes
It is Botello's notes, rather than those made by other medical personnel, on which Dr. Loughran bases his conclusion that Higgins may actually have had a dislocated shoulder while he was in the Kane County Jail. He relied solely on her notes and had not read her deposition, in which she explains what her notes mean to her.
A malpractice insurer's claim study (NSO and CNA), quoting the nurse's note and the next note 21 minutes later
“Patient appears in no apparent distress or uncomfortable. He has a history of asthma and is currently wheezing and difficulty breathing. Airway is patent, respiratory effort is even and unlabored. Respiratory pattern is regular, symmetrical. Breath sounds with wheezes bilaterally in both upper and lower lobes. Patient given Albuterol Atrovent and Prednisone per order. No adverse reaction.” At 6:59 p.m., the ED practitioner noted: “Patient having mild respiratory distress, respirations include accessory muscles, breath sounds are wheezing, moderate and heard diffusely. Cardiovascular indicates that he is tachycardic.”
An appeals court, listing the evidence of inadequate care after a resident was charted as fine
(2) failed to conduct adequate checks that would have revealed Renee's hip fracture sooner; (3) left Renee with a serious fracture overnight until Ilene discovered her in intense pain the following morning; (4) denied Renee needed any further evaluation;
The defense expert, using the nurse's overnight note as evidence
Dr. Schenk testified had Renee broken her hip on April 6, she would have been "screaming in pain" when transferred from her wheelchair to her bed and would not have been able to sleep through the night or eat as stated in her treatment note.
A record the jail's director of nursing signed said “no distress noted” while the patient's IV antibiotics were not being given: 14 doses were missed over a week. She testified that if a doctor's order had gone unfollowed for seven days, “the integrity of delivering nursing care would have been breached”. The court found enough evidence for a jury and reversed the summary judgment that had ended the case for her.
The medical encounter record, which Manning signed, documented Wilson's medical condition, provided her doctor's name, and stated “no distress noted.”
The other side of it. The nurse's “no distress noted” sat next to findings: color, pulse, circulation, motion, sensation. The court relied on those notes and affirmed summary judgment for the individual defendants. The same notes were also what the patient's expert built his case on.
Botello did check his arm at this time. Her notes say it was warm and pink but that his pulse was strong and his circulation, motion, and sensation were good. At her deposition Botello explained that what she was doing was checking to be sure that his nervous or circulatory systems were not affected by any possible injury. She noted on the chart that he was "sitting in a chair no distress noted."
Write instead
0400 Pt asleep on L side, easily rouses to voice, oriented x3, denies pain, back to sleep. Lungs and skin not assessed, deferred to 0600 to allow rest.
Every change shows. The record keeps the time of each entry and each deletion.
Correct your charting errors in accordance with your organization’s policies and procedures, ensuring that it is clearly marked as a late entry. Remember: electronic healthcare records automatically date and time each entry and identify electronic deletions, so any attempt to alter the patient healthcare information record is discoverable.
Not to protect yourself. A note added after an incident to cover the gap reads as guilt.
Don’t chart defensively after an incident has occurred. This is a red flag to lawyers later on. Defensive charting is not necessarily going to stand up in court as actual evidence of negligence, but it does telegraph the message that you believe you were at fault, and that’s the red flag the lawyers will be looking for.
Got a subpoena or a deposition notice? Call your liability insurer and your risk manager before anything else.
The first action nursing professionals should take is to inform their professional liability insurance provider and employer’s risk manager or legal counsel of the deposition notice.
The hospital's lawyer is not your lawyer. They represent your employer.
Keep in mind that this attorney is not your attorney, but is your employer’s attorney; therefore, you may wish to retain a board certified healthcare attorney or a litigation attorney to be “on your side” for the deposition.
You can describe your routine. What you always do is evidence too, but it is weaker than the note.
You can speak about your custom and practice in general at deposition, but there is no substitute for a well-written note and initialed treatment boxes.
Not legal advice. Your facility policy, your state and your
own attorney are what bind you. Every question and every quote here links to
where it was published; read the source, not us. Written by a med-surg RN,
ten years, day shift. Why there is no name on it.