Professor DrPuteriNemieJahnKassim is a Professor at the Civil Law Department, Ahmad Ibrahim Kulliyyah of Laws, International Islamic University Malaysia. She obtained her Bachelor of Laws with Honours from the University of Southampton, England and her Masters of Comparative Laws and Doctor of Philosophy in Law (PhD in Law) from the International Islamic University Malaysia. She further completed an Academic Fellowship at the National University of Singapore in 2006. She has written extensively in local and international journals in the area on medical law and ethics and has authored several books including “Nursing Law and Ethics” which was published by International Law Book Services in 2012.
Nursing documentation is an integral part of nursing and midwifery practice. It is a tool of professional practice that helps in the care process. When matters are brought to court, these documents furnish documentary evidence on the course of care of the patient. They are thus, legally supportive documents in a court hearing and crucial in defending allegations of medical malpractice. Undeniably, poor documentation will not provide a complete picture of three important aspects of record keeping, namely, patients’ needs for nursing intervention, interventions provided and effects of interventions when compared with patient’s report. Poor documentation tend to cause negative implications in many aspects whereas good documentation allows actions to be defended by peers in the event of conflict or litigation. This presentation seeks to discuss the nature and scope of nursing documentation and its relevancy as well as implications in court proceedings. The outcome of poor documentation will be illustrated in the discussion of various case laws from selected countries. The understanding of good documentation characteristics will eventually protect the nurses’ and the hospitals’ interest against untoward consequences in disciplinary hearings and legal proceedings.
Audience take away:
- Understand the nature and scope of nursing documentation and its relevance in legal proceedings
- Understand the characteristics of good documentation versus poor documentation and its implications in a court hearing
- Understand the effects of poor documentation in the outcome of selected court cases