On Monday, December 21, 2009 I received a subpoena for a case that is going to court regarding a patient I took care of March 15, 2008. That is almost two years ago, 21 months ago. Do you know how many patients I have seen and forgotten since then? Now I have to remember this one, single patient.
I called risk management and legal immediately to find what I was supposed to do. They called me to their offices and had all the documentation for the patient’s entire stay laid out so I could see it. I triaged this patient for a minor trauma that occurred ten days before she came in for care. She had no pain, stable vitals signs and no issues what so ever. She just wanted to be checked out.
Looking at my documentation didn’t help me remember her at all. But it did show me exactly what I did for her. It showed me how I made the triage decisions I made and why. I was able to see what her complaint was, what assessments I made and what decision I made.
It’s funny because whenever I would orient a new nurse in the ED, I would always tell them that their documentation needed to be complete enough so they could sit in court and explain what they did, even several years from. Thankfully I followed my own advice.