Empowering Nurses at the Bedside and in Business

To Document or Not, That is The Question

Usually, inspirations for my blogs come from either my own past experiences or recent news items.  However, the one I’m about to share here came to me from Nurse Erica by way of Facebook Reels.  She had been hearing of a director in Houston who directed their staff not to document any provider’s name nor to quote what the provider had said. 

This goes against Nursing 101 and documentation! 

The whole purpose of documentation is to create a legal record of what actually happens.  If you are not allowed to document the provider’s name or even what the provider said, how is this fulfilling the exact requirement of keeping a legal record of what happened? 

This is flat-out wrong and will get you in s-e-r-i-o-u-s trouble! 

If you are working in an environment where you are told to do something that YOU ABSOLUTELY KNOW to not be the proper way to do things, remember what I always say, “You can always find another job, but you can’t get another license.” 

I guess I probably shouldn’t say that I am shocked at the lengths to which some facilities will go to protect themselves and their providers from malpractice, but, if this is true to any degree, it is truly sad. 

Can you imagine what a jury would think if nurses had been told to hide a doctor’s name or omit any record of what the doctor had said? 

I am just curious to hear if you have ever been told anything like this where you work.  I would love to hear in the comments below. 


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