“Tolerated well.” What gets asked about it, and what to chart instead

On the stand · 6 of 12

Tolerated well.

Tolerated what? How well? It does not say what you assessed. With findings around it, the same words can hold up.

What they ask about it

What a plaintiff attorney asks after pain medication (ED Legal Letter, with a ProAssurance claims director)
Did you check the patient again after you administered the pain medication?
If the patient experienced a bad outcome after receiving pain medication in the ED, the plaintiff attorney is sure to ask these two questions: Did you check the patient's vital signs before you administered the pain medication? Did you check the patient again after you administered the pain medication?
Source: ED Legal Letter: ED Claims Involving High-dose Analgesics Carry Jury Appeal, 2017
A nurse-attorney, on charting before it happens
I have actually seen charts where people wrote ‘patient tolerated procedure well’ only to have the patient bleed out during the procedure, and then you are in the position of having to defend how and why you charted in advance.
Source: Oncology News International: Defensive Documentation Reduces Liability (Marilyn Frank-Stromborg, EdD, JD), 2000
A health-law attorney, on charting what you did and how
How will you testify years later, with no actual recollection of the patient in question, that you did it right?
You need not just to chart what you did but how you did it. Otherwise, how will you testify years later, with no actual recollection of the patient in question, that you did it right?
Source: The Health Law Firm: Florida Nursing Law Manual, ch. 22, Legal Aspects of Nursing Documentation, 2008

It happened in court

Hernandez v. Chalmette Medical Center

Court of Appeal of Louisiana, Fourth Circuit · 2004

The nurse had no notes of the child showing pain and said she would have charted it. The court still found the expert testimony clearly supported that he suffered additional pain from the failed first attempt.

Moreover, although Ms. Scardino said she had no notes of Chris exhibiting symptoms of pain, and that she would have noted it had she observed it, Dr. Blaylock's testimony clearly supports a finding that Chris suffered additional pain as a result of the failed attempt at reduction.

Strange v. Shroff

Court of Appeal of Louisiana, Second Circuit · 2003

Here “Tolerated well.” closed a note full of findings: lungs clear, bowel sounds, no nausea, walking in the hall. The jury found no malpractice and the appeal affirmed.

At 8:30 Dr. Cummings visited. New orders were noted. Encouraged to ambulate. Lungs clear. Abdomen soft with audible bowel sounds noted. No complaints of nausea and vomiting this a.m. Heplock intact left forearm. Site healthy. Ambulating in hall with husband. Tolerated well.

Sparks v. St. Luke's Regional Medical Center, Ltd.

Supreme Court of Idaho · 1988

The ICU note said the treatment was tolerated very well at 4:30 p.m. Fifteen minutes later the same notes record cool, clammy skin and shortness of breath.

4:30 p.m. IPPB tolerated very well. Stopped occasional for patient to cough. Orally suctioned approximately 10 cc thick creamy yellow production. 4:45 p.m. Skin cool and clammy, color pale. Patient complained of shortness of breath.

Write instead

Walked 30 feet; denied dizziness or dyspnea; gait steady with walker.

Charting the response to care

Already charted it this way?

Do not change the original entry. Not for any reason, and not after you hear there is a claim.
Never alter a patient’s record - that is a criminal offense
Source: NSO: Do's and Don'ts of Documentation
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.
Source: NSO, Defensive Documentation: Steps Nurses Can Take to Improve Their Charting and Reduce Their Liability
Add a late entry, the way your policy says. Mark it as late. Write only what you actually remember.
If something needs to be added to documentation, always chart that information with a notation that it is a late entry and include the time and date
Source: NSO: Do's and Don'ts of Documentation
Use the time you are writing it. Name the time of the event inside the entry; the entry itself carries today's time.
Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time.
Source: ACDIS Q&A: Policies for late entry documentation
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.
Source: The Health Law Firm, 25 Legal Dos and Don'ts of Nursing Documentation
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.
Source: CNA and NSO: Nurse Spotlight, Preparing for a Deposition
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.
Source: The Health Law Firm: Preparing for a deposition, for nurses
At the deposition, do not guess. Answer what you saw and what you know. Not remembering is an answer.
7. If you do not know the answer to a question, do not guess. Say that you do not know the answer. 8. If you do not remember something, say so.
Source: CNA and NSO: Nurse Spotlight, Preparing for a 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.
Source: I Advance Senior Care, Nursing depositions: Duty or disaster?

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.