“Patient refused.” What a court asks about a charted refusal
Exhibit 3 a refusal
Patient refused.
Refused what? It hides which care you offered, the patient's reason, what you explained, and who you told.
What they ask about it
An appeals court, on what the chart and the nurse did not show
However, the nurse did not testify that she specifically discussed with the decedent any specifics of her possible condition, nor do the medical records reflect any such detailed discussion.
A malpractice insurer's claim study (ProAssurance)
Notably, there was no mention of an endometrial biopsy in the patient’s record, no mention of the patient’s refusal of treatment and no mention of the risks associated with failure to undergo further studies. The NP’s defense would rely primarily on her testimony.
A chart entry by a staff member that “the patient refused” is not sufficient to meet the requirements of NCCHC standards A-08 Health Records and G-05 Informed Consent and Right to Refuse.
Appellate Division, Second Department (New York) · 2024
The chart recorded that the patient declined transfer to the ER, but not what she was told about how serious it could be. That gap kept the claims against the cardiologist and the practice from being dismissed.
Although Sheth's medical records stated that the decedent "decline[d] transfer to ER for [t]rop[onin]" testing, the records did not indicate that he specifically counseled the decedent as to a potentially serious medical crisis requiring immediate emergency hospital monitoring and treatment. The records contained no mention of any possible proposed hospital treatment, apart from troponin testing, nor as to any discussion of that matter with the decedent.
A nurse whose patient left against medical advice was found to have engaged in unprofessional conduct for not giving accurate and complete information about the risks.
In a detailed written decision, the District Court found that Zablotny had engaged in unprofessional conduct by failing to provide the patient with accurate and complete information about the risks he faced upon leaving the hospital against medical advice.
The resident probably refused baths, but there were no nursing notes for seven months and no bathing records, and the facility's director agreed the refusals belonged in the notes.
Caldwell could not explain why there were no nursing notes for Paul between January 2019 and August 2019 nor any documentation of Paul’s bathing schedule. She agreed, however, that if Paul was noncompliant with bathing, that was something she would expect to see in the nursing notes.
Write instead
0900: Scheduled enoxaparin 40 mg subcutaneous offered. Patient declined, reporting painful bruising after previous injections. Dose not administered. 0910: Dr. Chen notified of refusal and patient's reported concern.
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.