More recently Elliot and Liu (2010) proposed Nine Rights.
Order a More recently Elliot and Liu (2010) proposed Nine Rights. paper today!
1. Right drug 2. Right dose 3. Right route 4. Right time 5. Right client 6. Right reason 7. Right documentation 8. Right form 9. Right response
Marcos, the nursing student described earlier in this chapter, violated the right-dose principle and therefore made a medication error.
Appropriate Documentation
The adage “not documented, not done” holds true in nursing. According to the law, if something has not been documented, then the responsible party did not do whatever needed to be done. If a nurse did not “do” something, he or she will be left open to negligence or malpractice charges.
Nursing documentation needs to be legally credible. Legally credible documentation is an accurate accounting of the care the client received. It also indicates the competence of the individual who delivered the care.
Charting by exception creates defense difficul- ties. When this method of documentation is used, investigators need to review the entire patient record in an attempt to reconstruct the care given to the client. Clear, concise, and accurate docu- mentation helps nurses when they are named in lawsuits. Often, this documentation clears the indi- vidual of any negligence or malpractice. Documen- tation is credible when it is:
■ Contemporaneous (documenting at the time care was provided)
■ Accurate (documenting exactly what was done) ■ Truthful (documenting only what was done) ■ Appropriate (documenting only what could be
discussed comfortably in a public setting)
Box 3-2 lists some documentation tips.