Legal Issues And Documentation

Question 1

Patient records when used as evidence

Answer 1

CIVIL PROCEEDINGS

• against healthcare providers
• a patient record often used to support allegation that wrong treatment was given

CRIMINAL PROCEEDINGS
- evidence that assault/injury took place and the nature and extent of the injury

Question 2

Coronial hearing

Answer 2

• purpose of inquiry to determine nature and cause of death
• records can track deterioration, or identify errors and ascertain initial condition
• such records subject to close and careful scrutiny
• good records can be valuable in court

Question 3

The purpose of report writing

Answer 3

• integral part of nurses work
• should constitute patients healthcare
• assessment of progress
• record of treatment given, progress made and hx for future consultation
• teaching purposes