The nurse is caring for a client with uncontrolled hypertension. His blood pressure has remained controlled for the nurse's shift. At 2-hour intervals the blood pressure was checked by the nurse and found to be essentially the same
The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the client has a stroke. Years later, the client files a lawsuit blaming the hospital for his stroke. The nurse who was caring for the client when his blood pressure was stable cannot recall the exact blood pressure she obtained, but remembers it was normal. Will this recollection suffice in court and why?
A) Yes, the nurse remembers the pressure as normal during her shift and can swear to it during the deposition.
B) No, but it will relieve the nurse of any wrongdoing.
C) No, if the blood pressure measurement was not documented, it did not happen.
D) Yes, the nurse was not on duty when the stroke occurred.
Ans: C
Feedback:
Legal cases have been argued with the principle that "If it was not documented, it was not done." For this reason it is important to document normal as well as abnormal findings. Because nurses and other health care team members cannot remember specific assessments or interventions involving a client years after the fact, accurate and complete documentation at the time of care is essential.
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Fill in the blank(s) with the appropriate word(s).