The nurse is caring for a client with uncontrolled hypertension. His or her blood pressure has remained controlled for the nurse's shift. At 2-hour intervals, the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the client has a stroke. Years later, the client files a lawsuit blaming the hospital for the stroke. The nurse who was caring for the client when the client's blood pressure was stable cannot recall the exact blood pressure readings obtained, but remembers it was normal. Will this recollection suffice in court and why?
A) Yes, the nurse remembers the pressure as normal during his or her shift and can swear to it during the deposition.
B) No, but it will relieve the nurse of any wrongdoing.
C) No, if the blood pressure measurement was not documented, it did not happen.
D) Yes, the nurse was not on duty when the stroke occurred.

Question

Quizplus · Accepted Answer

Legal cases have been argued with the principle that "If it was not documented, it was not done." For this reason, it is important to document normal as well as abnormal findings. Because nurses and other healthcare team members cannot remember specific assessments or interventions involving a client years after the fact, accurate and complete documentation at the time of care is essential.

The Nurse Is Caring for a Client with Uncontrolled Hypertension