How Nurses Can Improve Observations to Avoid Accusations

As a nurse, the most important thing you can do to ensure the safety of your patients is to properly observe, assess and monitor each and every person under your care. If you fail to do so and an injury or death occurs, you may be subjected to disciplinary action or even held legally liable.

Most legal cases involving improper observations by nurses don’t involve out-of-the-ordinary circumstances or complicated situations: they are caused by small errors or failure to adhere to basic principles of practice.

Below you’ll learn more about how you can protect yourself from liability and disciplinary action by improving your nursing observation practice.

Provide Sufficient Observation and Assessment

When observing your patients, it is essential to do so continually rather than occasionally. A patient’s condition can change and decline quickly, so monitoring patients at regular intervals is crucial.

It’s also imperative that you trust your judgment when considering how often you should monitor a particular patient. Even if an advanced practice nurse or physician has ordered you to observe a patient less frequently, you should increase your observation of the patient if you feel that it is necessary.

Properly Document Observations

Sometimes the only way to prove that you have properly observed a patient is to document it in writing. If you fail keep a written record of your patient’s condition, there is no proof that you checked their vitals, gave them medication or otherwise properly cared for them.

This means that even if you have properly monitored a patient, unless you recorded your observations you could be held legally liable for an injury they incurred or be subjected to disciplinary action. Any time a patient’s condition changes, you should document it in the patient’s record and notify their healthcare team. When notifying the health care team about changes, you should be as specific as possible so there is no doubt as to the action you have taken. Always take the time to clearly describe clinical signs and symptoms as well as your response.

Stay Up to Date on Your Clinical Education

Medical technology and best nursing practices are constantly changing, so it’s essential that you stay up-to-date in your practice area. In addition, you should ensure that you always have the most recent information on the signs and symptoms that are affiliated with a patient’s diagnosis. If you have a patient whose diagnosis you are unfamiliar with or have not experienced in some time, take the time to refresh yourself.

Hiring a Nursing License Defense Attorney

Although careful observation, monitoring, and documentation can protect you from being held liable for a patient’s condition, you should always be ready for the unfortunate possibility that, in the case of death or injury, you will be held legally accountable. If you find yourself in a situation where you are being subjected to disciplinary or legal action, it is imperative that you contact a lawyer right away.

If you need help during a nursing complaint, contact nursing license defense attorney Scott J Harris. Click to schedule a free, 30-minute consultation or call us at 323-794-0701 or at 877-865-6218.

This blog is meant to be informational. It is not meant to be all-encompassing legal advice. If you are facing a situation involving your professional license, seek counsel from a licensed attorney.