◙ MEMORIES DIM, BUT THE RECORD REMAINS On average, malpractice suits take place 3 to 7 years after the incident occurs, say Carmen Lester, RN, BSN, JD, CPHRM, and Jan Kleinhesselink, RN, BSHM, CPHQ, of Lincoln (Neb.) Surgical Hospital.

Sloppy documentation is equal to sloppy care. As you learned in nursing school, if it wasn't documented, it wasn't done, a point Carmen Lester, RN, BSN, JD, CPHRM, and Jan Kleinhesselink, RN, BSHM, CPHQ, of Lincoln (Neb.) Surgical Hospital repeatedly drove home during their well-rehearsed presentation that was more like a stage play. With great rhythm and precision, the nursing colleagues and close friends walked and talked their audience through a real-life malpractice suit at their facility, from scary start to fortunate finish.

"In court, the medical record is the care rendered," they say. "Jurors view good record keeping as an indicator of good care — poor documentation can create an aura of poor care and damage the credibility of the healthcare providers."

The details of the wrongful death case: A 39-year-old male patient, a married father of 6, underwent a successful finger amputation at the surgical hospital in 2005. He was discharged 2 days after the surgery. The man's family said he was discharged too early and his pain wasn't under control when he went home. He died at home 3 days after discharge of what the coroner ruled was a painkiller overdose. The hospital said the death, while tragic, wasn't a result of anything it did but rather a result of the man's taking too many pain pills once he got home.

The case went to trial 7 years after the date of the incident. After that much time, witnesses may be unavailable and memories are dim, but the medical record remains. The handwritten notes were sloppy, both in meaning and penmanship. The electronic record was not much better. Dropdowns and charting exceptions didn't correlate with assessments and nurses' notes.

"When the medical record is being scrutinized by 12 jurors, it's very disconcerting as an administrator to realize the things you assume are happening are not," say Ms. Kleinhesselink and Ms. Lester. "To have these failures blasted by the plaintiff's lawyer during trial makes you want to climb under the defense table."

During the 8-day trial, plaintiffs' lawyers hammered away at contradictions, inconsistencies and omissions in the notes. The plaintiff's nursing expert testified that the facility fell below the standard of care in pain assessment, and didn't fully comply with its policies and procedures.

The family's attorney asked the jury for $1.7 million. But the family got nothing. In the end, the jury found that the plaintiff had failed to present evidence that tied the hospital directly to the death of the patient. There was great relief, yes, but also a great lesson learned.

"Defending a case this old is very difficult," they say, "and we learned we needed to make further changes to our documentation policies to better protect our staff and the facility."