Nurses are active in risk management

I am about to begin an interesting new task on the busy obstetrical unit at the hospital. My task will be to audit medical charts of patients recently cared for within the unit-- and they need a nurse to do it.

I am excited by this opportunity because it is another demonstration of the important role nurses play within the medical industry. This is not a blame game. The risk management team for the health authority recognizes that nurses are uniquely qualified to evaluate the documentation of patient care. Not only do audits check to see if policies and procedures are being followed but also if a complete course of care can be tracked for, in this case, multiple patients under one system (mother and baby or babies).

We all learn from doing and sometimes a gentle reminder of what was missed or a congratulatory note of a task well done may lead to improved documentation that assists the legal team in a case up to twenty years down the road. On that note, what were the charting practices ten or twenty years ago? Is your team prepared to deal with "exception charting" or "SOAP" charting that were common directives then?

A legal nurse consultant cannot be a recent graduate of a school of nursing because policies, procedures, knowledge, equipment and, yes, even charting were not the same even five years ago. This is a specialty area of nursing where experience is the rule not the exception and it is an exciting opportunity for these senior nurses to use their background in a whole new way!