Documentation and the Coroner

Question 1

Why is quality documentation important?

Answer 1

Documentation is a legal requirement and provides legal protection for nurses. In the eyes of the court “if it wasnt written it didn’t happen”. Documentation also allows:

• effective communication between the healthcare team
• provides an assessment and evaluation of patient progress

Question 2

When are patient records used as evidence?

Answer 2

Civil Proceedings: when a case is brought against a nurse the patients record will be viewed to support allegation of wrongful treatment

Criminal Proceedings: patient record is used to show that assault/injury took place and the nature and extent of the injury

Question 3

What are the guidelines for quality documentation?

Answer 3

1) Document facts: what was done, heard or saw
2) Document ALL relevant info: changes of condition, any treatments given and effect
3) Document Contemporaneously: ASAP after event
4) Maintain integrity of documentation: do not change or delete errors (looks like covering something up)

Question 4

What are the Standards of Documentation?

Answer 4

• Clear and accurate as well as legible and in english
• Use of state approved abbreviations only
• Written in black ink
• Date and time correctly entered on each entry
• Signed and name printed by author, designation
• Written objectively with the absence of demeaning remarks
• Sequential
• Made at time of event or “in retrospect”

Question 5

What is the role of the coroner?

Answer 5

Independently investigates death to determine the identity of the patient, the circumstances and cause of death. Overall investigates and makes rulings about a persons death.

Question 6

What are the circumstances when a death must be reported?

Answer 6

• If the death was violent or unnatural
• The death was sudden and cause unknown
• Death resulted from accident or injury
• Occurred following a health-related procedure
• The person was in or recently resided in a MHF
• Identity of deceased in unknown
• Death occurred in custody
• The deceased was a child in care

Question 7

What additional powers does the coroner have?

Answer 7

1) To make additional recommendations that will improve public health and safety
2) Power to summon witnesses, issue subpoenas and order arrest
3) Power to refer to director of public prosecutions if coroner has evidence to believe the coroner committed the crime