We've all heard the saying, "Not documented, not done." Don't let yourself end up in a nursing litigation case, unable to remember the care you provided to your patient because you failed to document the most important thing you provide: quality patient care. These practical tips will help you prevent nursing litigation in patient positioning.

1. Diligently document the care provided
Documentation of patient care should provide a story about the care provided to your patient. In litigation, the medical records provide a picture of the patient's care and treatment in surgery. Ensure your documentation paints a factual picture of your patient's surgery and surgical position, including who, what, when, where and how.

Document the patient's pre-operative conditions, including skin integrity as well as physical and mobility limitations. Be sure you or a team member has checked pre-operative skin integrity, implantables and mobility status. This information will allow for a comparison to the post-op condition. Note on the operative record if a patient has a pre-existing skin condition, such as a rash, bruise, scrape or burn.

2. Be detailed and complete in your positioning documentation

• Include the names or initials of all parties involved in positioning the patient, including those who aren't a part of the surgical team but were present in the OR to assist with patient positioning. This may include ancillary staff such as anesthesia technicians.
• Note the specific position the patient was placed in for surgery. For example, if the patient is placed in a lateral position, indicate which side of her body is placed up or down. Also note the devices and aids used in positioning and their exact location of placement. If the patient is placed in the lithotomy position, indicate if it is high or low. If the patient is placed in stirrups, indicate the type.
• When multiple surgical procedures are performed on one patient and they involve two different positions, document which position and device were used for which surgery.
• Document that the surgeon and anesthesiologist confirmed and verified the patient's position.
• Only use the approved abbreviations for your facility when documenting patient care. This helps to improve the effectiveness of communication among all caregivers and ensures patient safety.
• Date, time and sign all of your documentation. In litigation, the dates and times are often referred to for a timeline of patient care events. Ensure that the times you document - in the room time, surgery start time, surgery end time and patient out time - match the anesthesiologist's records. These may be compared to review discrepancies in care.
• If documenting by hand, always write legibly so that all caregivers can interpret the information. If the records are used in litigation, it's imperative that you and the legal team are able to read about the care delivered, since it's more likely that you won't remember the scenario without the proper documentation.
• Review your documentation before signing to ensure you've recorded all the needed information about the patient's position. Remember, "not documented, not done." If you fail to document a positioning aid that was used for positioning (such as an axillary roll) and the records are reviewed in litigation, you'll have a very difficult time proving the aid was used and didn't cause patient injury.
• Document if there are any changes to the patient's skin integrity or if an injury is noted during the post-op patient evaluation. If a positioning injury occurs and you note it at the end of the case, document it as an unanticipated outcome. This change to the patient's status post-operatively is relevant to document so that it may be followed up on throughout the patient's remaining care.

Take a timeout immediately before starting the procedure Know and follow your facility's policies and procedures for performing the surgical timeout. Take the timeout in the location where the procedure will be done, just before starting the procedure. It must involve the entire operative team, use active communication and be documented. AORN suggests the timeout also include the "correct patient position" and has requested that Joint Commission add correct patient position to the timeout.

Re-evaluate your patient's position if modified during the surgery In some procedures, the patient's position may be changed or altered in some manner. If this happens, re-assess her body alignment and tissue integrity and document that you have done so. Should the surgeon ask a member of the surgical team to adjust the positioning devices or reposition the operating table during surgery, re-assess the patient's status in the revised position to prevent a complication from occurring. A device, padding or a body part may become dislodged or loosened with movement, which could lead to a serious injury. In addition, the change to the patient's position may expose or damage otherwise protected body tissue and lead to patient injury.

Slow down for a second
Obese patients, amputees and those with contractures often present a challenge in positioning. Once you've positioned the patient, evaluate her body alignment and tissue integrity. Keep in mind that the patient must be able to tolerate this position throughout the duration of surgery. A patient can't tell you if the position is hurting her. Even though you're moving at high speed trying to keep the procedure running on schedule and keep turnover time down, it pays to slow down and ask yourself how you'd feel if positioned in the manner the patient is and how you can make the position as comfortable and safe for this patient as possible.