Documentation Mistakes That Could Cost You Your License (With Maggie Ortiz)

Welcome to Club Nurse. I'm Colton Lord, your host. By you being here today, it shows me that you are someone who wants to learn, grow, laugh, connect, and just let your emotions flow. We are here to share real stories and hear real-life experiences from real people. You are not alone in this, and Club Nurse is here to show you that. Don't forget to follow the show and share today's episode with someone you love. Now let's dive into today's Welcome back to Club Nurse, everybody. My name is Colton Lord, your host of this podcast. I have a super interesting guest with me here today that I actually— I met Maggie at the health conference that was in Las Vegas. That's where we kind of ran into each other. So I have followed along with you. I've seen you on LinkedIn and the things you do on socials. And I think what you do is very interesting. And I think I actually just saw— I think this was literally just coincidence. I think that nurse.org just had done a feature on you, is that correct?

Yeah, totally cool. And I've done a podcast or 2, and then I've written some articles.

Okay. Yeah, so it was literally just coincidence. Like, I saw that they had posted something the other day with you, and I was like, oh, I'm literally having her on as a guest, um, for my podcast. So for the audience, do you mind just introducing yourself? Tell us who you are and what you do in the world of nursing.

Sure, sure. So I've been a nurse for 25 years, started my associate's degree, did a bridge at about 15 years because everyone knows that you're not going anywhere if you don't have your bachelor's. So I did a bridge, my ADN to my MSN in leadership. I've never done leadership, always done pretty much hospital. So ICU, ER, pre-op, PACU, endo, IR, cath lab, structural heart, everywhere but labor and delivery. I do like to joke.

Yeah.

Agency, float pool, travel nursing. I did spend time at the Board of Nursing I did go to national training, so I had to learn the rules and the regulations intimately, and then how to use that when a nurse has been reported. I didn't stay very long. I left the agency and I started advocating for our profession. Most of us do not know the rules and regulations that dictate our professional practice. So I became an activist and advocate. And so now I primarily help nurses and their legal teams when they're under investigation, primarily through education resources. Or a hospital system, a school. It just depends on whom's reaching out to me.

Okay, so what what your what your company? It's your company, right? The Advocates for Nurses. Okay, so that's what it's called: Advocate for Nurses. So tell us exactly. I know you kind of just touched on that. So what exactly is? So say something happened with a nurse. They got you know for whatever reasons a peanut or something, and they needed some help. Like what is your role in helping in the process of? Um, when they get this information?

Well, that's a great question there, sir. And so actually, I was just responding to an email before I got on. So it depends on what type of law the nurse is involved in. Some of us, you know, there are 3 types of law, just for all essential purposes. So if, let's just say, this nurse that just reached out to me is being deposed— so I did write a book, Help, I'm a Nurse, I'm Being Deposed, under civil litigation. So in that realm, I cannot help you at all. I can't really even speak to you because that's a different type of litigation. But I wrote that book, You Do Have Rights as a Nurse. And so that's some of the stuff that I can talk to you about. I'm going to guide you to the book and then I'm going to maybe even give you some just basic information. What does it mean to be deposed? What's the definition of that? What are your rights? And then we're going to talk about if you were the primary nurse and there was a poor outcome, you should probably get your own legal representation. If you took a blood sugar on a patient and your name was in the chart and everyone was named, that's— I'm not— you see what I mean?

Yeah.

So those are some of the things that we talk about. The bulk of the stuff is a nurse is under investigation by a board, they've gotten a letter, and so we start talking about that kind of stuff. Or it's the lawyer that reaches out to me. The lawyer reaches out to me and says, I'm representing a nurse. You know, this is what's going on, and then so we talk, and then from there it's decided whether I will be the expert or the consultant. Because if I don't have the same or similar modality for experience, I've never done long-term care, right? So I couldn't, and it wouldn't be a service to the nurse to give my opinion or help guide the attorney because that's not my modality, and that would never meet the criteria. and civil litigation. So, if a nurse under investigation by board reaches out to me, that's the bulk of the stuff that I do around education, what it means. Just, there's so many things that go along with that. Criminal, it's going to end up in front of the Board of Nursing. So, I oftentimes will tell nurses, it's in your best interest to consult an administrative lawyer right now and get them hooked up with your criminal attorney, just like if you had— you know, cancer, your primary care physician is not managing that.

Mm-hmm.

The hemoc— the oncologist is. So you need— because there's things that one cannot see that the other— the criminal attorney will try to get something adjudicated. Adjudicated means that, like, you pled, or they're not saying— and I don't know all the words, but you, you're just pleading, which the board sees as guilt. But if your attorney in the criminal world is trying to get you what they feel is the best outcome there, and the Board of Nursing attorney or the administrative attorney is like, whoa, whoa, hold on. So this has to be dropped, or we have to use different language, or he or she will have to stand in front of the Board of Nursing, or he or she will end up with violations that we won't be able to get out underneath. And I know I just dropped a lot, so I know there's some questions. Um, there, but that's kind of just like the skim over of some of the stuff that I do.

So yeah, so with all of that, I mean, what— so what's your take on, do you think that every nurse should have their own separate, um, like liability insurance that helps to like cover with these things? Or do, like, do— in your experience, do— if something's happening, do the hospitals appoint somebody like a lawyer for the nurse to represent? Or how, like, is it Sure.

Great question. I get asked this a lot. So you would want to have both. So let's go back to the first scenario. You're the nurse that did the blood sugar on a patient. You were not the primary nurse. The defense attorney— and I had a defense attorney on my podcast December, and he was with the hospital— the defense attorney has to tell you as the nurse, I don't represent you.

Mm-hmm.

Right? Who's my check coming from?

From the hospital.

But would I be as concerned if I was the nurse and I did the blood sugar And I wasn't negligent. I was, you know, there was a civil case and there was a pressure ulcer and I did nothing wrong and I was dropped, right? But someone else was found negligent. So, and if I was the primary one in that case, 100%, I would have called on my own lawyer. I would have contacted the professional liability insurance and then we would have been having that discussion. If I was the nurse that just did the blood sugar, I wouldn't want to A, it's a claim on my insurance. And number 2, is it really financially responsible? Do I really need to spend that kind of money if I'm probably not even going to get called to a deposition?

Mm-hmm.

I may have seen the petition and the hospital attorney had to tell everyone that you could possibly be called, but people who actually get called to depositions are oftentimes key players because a deposition is pretrial. They're trying to figure out what happened. It's through discovery. They're getting the medical records through depositions. They're getting witness statements. Do you see they're trying to paint the picture of what happened? And so back to your question, it is situational. Go back to the scenario. If I was involved with criminal conduct, I would 100%— let's just say DUI because that's one of the most common ones that a nurse will get, could get caught up into. I would 100% call, if nothing else, if they could consult with one another, my own professional liability insurance to talk to my criminal lawyer to tell, lawyer, Criminal Bob, that this has got to be mitigated away as much as possible, but I would want them to talk. Does that make sense?

Yeah, it does. And I think that what I'm kind of gathering from this too is, I mean, obviously everybody forgive me if I use wrong terminology here. I'm not involved in any legal systems or whatever. It is confusing. So even when I'm hearing you talk about it, it's like, okay, I'm trying to connect all these dots. So is that where you step in? Because it is so confusing. There's all this terminology. These big words. Is that what you're stepping in to help the nurses to be like, okay, I'm going to help to guide you into these directions on what I think will be the best way for you to gather all the tools that you need to get through to the other side of this? Is that kind of like what you do in a nutshell?

Yeah. So great. And that's a great analogy. So think when the doctor walks in and just tells the patient they got diabetes or stage 100 cancer, peace out. They're there for five minutes, and like the same with the lawyer, right? They come in and they they want to get the best outcome, and they're doing something different. Think patient advocate, same thing. So that's where I'm coming. I'm like, okay, because the number one thing is that a nurse thinks is that they're going to lose their license. So that's the first thing again. I don't have a yeah crystal ball, right? I can't, but that's I try to get that off the table from first. I mean, someone has diabetes; you're not going to die, right? You have something that can be well.

That's where our brains go though immediately. And I. I've had those situations where like you're like, oh my God, like this just happened. Like I'm gonna lose my license. You jump to worst case scenario.

And then so that's one of the things I try to unpack. And so not only through verbal communication, I have like 52 handouts. I try to meet a nurse where they're at. I'm creating out modules so that a nurse could come to module 1, lesson 2, or module 5, and, and what is in a great order where there it is. It's 2 AM and you are losing your mind and no one is available to talk to you, I'm going to go to the module and I'm going to watch it, or I'm going to— you know what I mean? I have resources available to nurses and to lawyers as well. When I work with a lawyer, I also tell the lawyer, you know, just like when I— you know, you would— when we work with physicians, I have educational tools that of course I will show you. And if you're okay, those are things I would love to share with the nurse because I have found that through the education— shocker— Mm-hmm. You know, that's the epitome of everything we do—that the nurse's anxiety is decreased because they understand what's happening. So, to your point, that's all I do. It's no different if a physician is going to do a procedure; they have to come in and give the person informed consent. How does that happen? It happens through education. I provide the education. The nurse then has the ability to then make the best decisions for themselves, for the best outcome. Because if a nurse. comes to me, let's just say, for example, they did something in their life and they're a nurse and they want to— or they want to become a nurse. And let's just say they're involved in pretty egregious criminal conduct. Never any judgment, but let's talk about what that means. You go to nursing school, you're going to have to declare it. You're going to have to be under investigations. You may not be able to be bonded. Then the nurse might— the person might say, well, I think I'm going to try a different career. But it's through the educational piece that they're— I feel like they're able to make the best decision. Do I sign the agreed order? Do I sign the consent? But to your point, it's, it's all just educational because I'm just a nurse.

Yeah, but that— I mean, that's right, exactly what you're saying is I feel like that educational piece is what gives you the peace of mind to sleep at night as the nurse to be like, okay, you know, because I, I mean, I can take a personal story that I had. I think this is obviously like just All of our, you know, top fears in this field is being called to court. Oh my gosh, like, am I liable? Whatever. We've seen the big headlines of, you know, people like Radon DeVought and just like these things that, you know, catch our eyes, um, and our attention. But I, I did have a specific case. I've only really been called once and, you know, I don't, I, I'm curious to see like what your opinion is as far as maybe what, what I should have done. It was, I got a call from a, um, previous hospital I had worked at and it was just, I think it was a voicemail and I think it was, it was some lawyer. I don't exactly honestly remember who was calling me.

Mm-hmm.

But basically I just, I got the voicemail and my stomach just sank because it was like, oh, you know, like this case, if you remember it, I don't even remember.

No big deal. No, no big deal.

Call us please at your earliest convenience to discuss. And I, the craziest thing is I did remember this case, which I think you usually probably have a vague memory if it's being brought to that level. Um, like I did remember this. I was, I, I've worked most of my career in the ER, but I was working on the med-surg floor. Maybe like two years, one and a half years probably into my career, and it was you know I won't obviously give like too many details, but basically patient had was getting chemotherapy and had a some kind of reaction had to be upgraded to the ICU and had later ended up passing away in the hospital. Nothing directly that I had done, like no negligence on my end. The family was suing, and of course like I was the primary nurse when things you know the rapid response was called and she was upgraded again totally really. unrelated to how she died. But yeah, when they were calling me and asking me these things, in that scenario, is it better to just be like, refer to my documentation, even if you do kind of remember things? Because I feel like the more you say, the more you can kind of run yourself into like, oh, well, I don't really actually— do you actually remember? Or should you just say, refer to my documentation?

Yeah. Because again, you would say, my best recollection. Because again, to your point, tell me what you had 3 days ago for breakfast, Yeah. No, you don't. Stop it. Stop it.

Right. I mean, I eat mostly the same thing every day, but yes.

You know what I mean? And now it's your license, or now you're in litigation. Really? You're gonna extrapolate some story that you may or not remember? That's poor planning. You know what I mean? That's—

Yeah. Yeah.

No, no, no. You keep it to—

But in those moments, you're like, oh my God, like what? You know? Like, yeah.

No, no. No. To your point, you can say, in my normal practice, and that's what you should be saying, right? 'Cause in my normal practice, I call— I would've called a rapid. In my normal practice, right? That's the stuff that you say because you don't have an independent recollection, and that's what you say. Clearly, you know, I don't have an independent recollection, but let me reference the medical record. And I pray, I pray that the medical record— please, please write words. Please don't copy and paste. So then that, to your point, it comes down to that. And when nurses are like, I didn't write anything, I'm like, So, I mean, but help me out. I mean, what do you mean? I didn't write anything, I know, but I don't understand what you mean. Like, not one word? Not like—

Yeah.

Like, I don't— that's— and again, no, I try not— you know, I'm just jesting and not judging. But even like my girl Redonda, it's mind-blowing to me sometimes. Like, the lead counsel, I mean, they tell her not to document. And just think about in the moment, something just happened and you're relying on the other people and then nothing is documented. And then good luck. I mean, when have I seen? I have been to your point. I've been called to cases that I wasn't involved in, but to look at what the nurse wrote spot on beautiful that there was no there was no question about up up all the way to the house supervisor that there was this was post hurricane they were trying to get the patient to a higher level of care they couldn't and you know why there was a hurricane this was five years later what expert or what person Would go down to the nuance of weather. Now, I mean, I think that would be an excellent expert, but I don't know if someone would innately just start going down that road, right? Because why aren't they getting to a higher level of care? Well, here it is. So you know what that was? No nursing negligence. No nursing negligence. And there, that case could go nowhere. So it does come down to what you do or do not document. Don't over-document. I am all about Charting by exception. Why would you not? You do need to utilize— you better know your modality, right? When you're in the PACU, your phase 1 or 2, you're doing Aldrete's. If you're doing conscious sedation, you're doing Aldrete's, right? The emergency room, you're doing something different than I'm doing in the ICU or on the med-surg floor. So be very comfortable. And then the other thing that I see trip up nurses is a policy. They go straight against a policy. And I'm like, wow.

No.

That's probably not going to work out in litigation because, I mean, all that they're going to— the expert's going to be like, can I just read you the policy? I mean, I don't want to bore you with the details of your job, but do you see what I mean? And it's just not— and now you're, to your point, you're being deposed. You got that phone call, oh, no big deal, just come on down. And oftentimes, to your point, the legal counsel may not be in the building. It's a Uh, law firm that the— I don't know the exact words of its contract— or that utilizes but may not— they're not embedded in the hospital. We have risk management. They do have normally defense attorneys. They might have one, but I don't know. They normally have like a, a larger practice oftentimes that they may consult with when there's medical malpractice. Does that make sense? Because you would need legal counsel to do, I don't even know, contracts, who knows, right? But when it got down to some of the nut-cracking stuff, I have seen that they will use outside counsel because that's their bread and butter if there's litigation.

Wow. Yeah, it's all just interesting. And I think what I really wanted to touch on in this conversation was documentation, and you kind of touched on a couple things already. Obviously, just how Emphasizing how important documentation is, and I think that I, you know, especially for new nurses and even not new nurses, like this could be nurses switching specialties and documentation is a little bit different depending on where you're at. But I think yeah, like emphasizing the importance of documentation and how like literally every single thing can be picked apart word for word what you're saying, what you're doing, and you know the timestamps and everything. Like there's so much that kind of goes into all of it. So I had a couple like. like rapid-fire style questions I kind of wanted to ask you about documentation and kind of just get your, get your take on these. Um, so let's see here. The first one was, what's the, what's the number one documentation mistake nurses make that gets them in legal trouble? Copy paste.

In your experience, copy paste.

And is that from like their own, like copy and pasting like their own stuff from the day before? Or is it—

You're not allowed to do any of it. So great question, but you're not even allowed So, so, okay, if you're copy and pasting from a smart phrase, sure, you can do that. Are you allowed to copy and paste even from the same patient an hour, 2 hours? It shows a trend in poor practice, right? It's not necessarily about that one act, correct? Because now you know what you just opened you up for? Every patient you've ever just touched, you know what they're going to show? A trend in your behavior, and that's what they want. So no, because look at, look at Like, you'll see where someone wrote right, aka, and it was left, and how many people copied and pasted that. No. And to your point, all the audit trails, there's too many ways to— there's experts, even nurses, who all their expertise is in is audit trails. They interpret the audit trails or ask the attorneys what to ask for or help them interpret the audit trails. Does that make sense in a legal case? That's one person that's hired against you, right? That's going to gift that up for them. So copy and paste, that's a big no-no. Again, I'm like, I use the PICC line dressing change, like in my charting course. I actually teach a charting course. I have a charting course that can I copy and paste the— I would look at the policy, right? Because again, what I'm doing is directly from the policy. So I create my smart phrase. And if I like used an Opti 1000 as opposed to just a regular Tachyderm, that would be my only change in that smart phrase that I would insert. So I'm not reinventing the wheel because I'm, I'm doing a PICC line dressing change or central line, right? Just dressing change. You could do a smart phrase, but copying and pasting, like say you took care of that patient 3 days before and now you're just like redressing it, you're doing a whole and you're copying paste. No, no, no, you're not.

So are you even saying this in the— like, so say, because I've done— I've worked a little bit in the ICU. If you have a neuro patient that you're doing like Q15-hour neuro checks, are you even saying that you should be going through and like re-documenting every single time that you're doing it? Like, no copying and pasting that your assessment—

I would not, because why couldn't you just say assessment unchanged? Why do you need to copy and paste? Again, you're showing a trend in poor behavior because that's not a generally recognized standard of care for a best practice. No one— that's not recognized as the best practice ever anywhere. I mean, so the expert is going to pull peer-reviewed articles, research, and I mean, please the audience, pull one for me, but I don't know that to be best practice. Therefore, do you see what I mean? They're going to look at trend in the behavior.

Yeah, yeah, it's an interesting point. And I think the, the hard part for— I put myself at the bedside— is, you know, time. I mean, nurses will do anything to save time, and it's not obviously not It's not our fault that there is, you know, you're run so thin. Um, and so I, I understand, of course. I mean, I've done it a million times, like copy and paste my assessments and just things, especially in those settings where I've had the patient for a couple days, because you'll do, like I said, anything to just save time. You're not seeing it as much in the ER because, I mean, you're treating people acutely. Um, yeah, so that, that, that's an interesting, interesting point for sure.

You should just review that assessment, say reviewed assessment, Agree with previous assessment unchanged.

And then I just mean because like in the like I'm trying to think back like to like the flow sheets like where you have like your full neuro assessment if it's like a post TNK or TPA patient and then like the next you know you have you have to have like a full neuro. I don't remember exactly like the terminology that it says, but I'm pretty sure you have to fill out each column if I remember correctly. I could be thinking this incorrectly, but you're saying you should still go through it.

So now I hear you layering on a couple of different things that your organization has established, the software set up so that the nurse, when they're doing that flow sheet assessment, has to do that. Now, the other thing I would go to, because if I was going to deviate from that, if I'm seeing that there's some hard stops or whatever, then I'm going to go to the policy. Because if on the neuro assessment policy it says that I have to actually checkbox, then I just hijack myself.

Mm-hmm.

I'm not saying it's right. But then I do have to click box because the organization says that I do. But can we be involved with policies rewriting? Yes. Oftentimes we're just not at the table or— and I'm saying this respectfully— someone who hasn't touched a patient in a million years.

Yeah.

We do value their experience.

Sure.

So far removed from reality that we just have to sometimes remind them that this is an update, a revision in a policy. Because even I think another creator and I were talking about there was an organization that wrote in their policy that only an RN could touch an AED.

Oh, yeah. Yeah.

But in a hospital setting, I'm like, you know what that's called? A gift to litigation. I was like, get out. You've got to take that out. But you see how oftentimes we're not at these tables making any of these decisions. So I would Go to your educator. I would ask those kind of questions. The other thing is oftentimes when we do take on assignments that are not safe, and that's a whole nother show, that does cause us to not have enough time to document. Now, there could be the other things. A newer nurse wants to chart everything and doesn't know how to nuance it out. So there are some layers, but I have spent time with the informatics. Like, use the people in your environment. Like, the informatics people, they probably hated me. I don't care. I floated. Like, wrench my stuff in that I need here. Make me look like hers. Like, if I'm doing a cardio version of TEE, then I want it— then why can't mine look like hers?

Yeah.

So then I just called IT, and then they can just mirror wrench it in, is what they call an epic. But so, you see what I mean? Sometimes we have to advocate for safe assignments so that we are making sure that we have time to chart. And then there is a lot of nuances. Yes, we do chart for ridiculous reasons. It's not for— it's for cost capture. I mean, let's just be real, it's for cost capture.

Yeah, yeah. There's just even like talking about this, it's just like, oh my God, it's like so triggering as far as documentation. I mean, I still— I'm still work—

I still work as a nurse. You're gonna— you're gonna thank yourself, I promise you, if you're sitting in a courtroom And you're— if it's spot on and you're just right, like reading the gifts and your legal team and you're glowing, then do you see where I mean some of those nuances? You're going to be thanking yourself later on. Yeah, yeah, yeah, yeah.

No, I hear what you're saying 100%. It's just like one of those things that you're just like, I'm rolling my eyes at this, but it's so true. Okay, so let's see here. The next one, true or false? If it's not documented, it didn't happen.

True. Okay. You can say— this is when you— I teach you to say, but in my normal practice, that's where I'm mitigating circumstance. That's when I would be looking at— because again, if I saw something wasn't documented, we're looking at the schedule. Do you have any recollection? You would ask, depending on your scenario, board of nursing, I have asked for the schedule to be subpoenaed. I asked for the layout of the floor to be subpoenaed. We circled the assignments. We could see that the workflow wasn't reasonable. And when there was some failures to respond and obviously document, those could be seen in some other things. But again, depending on the setting, but you got to make sure you document to a certain degree. Yes.

Yeah. What's, what's your thoughts on, uh, we'll continue to monitor?

Ah, no, no, no, no, no, no, no, no. Because again, what are you monitoring? Go back to the same thing that you just said, you know what I mean? What if you have something that you are monitoring Then say that. Continue plan of care. I like that way better. Continue to monitor. Because what are you monitoring? The plan of care. If you want to write something, then continue the plan of care. Then I know what your plan of care, your nursing care plan. People don't even want to talk about the care plan. But you know, as the expert, you know what I have to go and look at? You know what's going to be used against you?

What is it?

The nursing care plan. Because that's the plan of care that you're allowed to create within your scope of practice. So as the expert, you know what, I have to go look at the nursing diagnosis that you created. I have to go and look at the plan of care that you created. Did you even update the plan of care? I've seen before where in the plan of care, let's just say it was pneumonia, you still had them on an Ambu rebreather. They've been weaned off of that. And yeah, you know what that looks like in litigation?

Nonsense. Yeah.

So the nursing care plan, people like poo-poo that. But that is what we learn in nursing school.

Yeah.

All of the care that we do is based on the nursing diagnoses that mirrors the medical diagnoses. And our plan of care is all around the nursing care plan based on the diagnoses. We just, we are just not writing them out any longer.

Yeah.

We already are just, we don't know that we're working within a care plan, but you are. All that training, Everything that you do every single day is the plan of care. You just don't want to call it the nursing care plan.

Interesting. I've never— I guess I've never heard that kind of brought back full circle. But I mean, it— I mean, it makes sense. You kind of already kind of touched on this one, but should nurses chart by exception or document everything?

Both. So chart by exception as a rule. If there's a fall, there's an incident, there's a code, please go ahead and do a SOPI. Go ahead and just, you know, Write on out some words. The same with the code documentation I've seen repeatedly. And I create— I'm co-branding actually with Susan Davis for the code documentation piece of it.

Oh yeah.

Because that is when, just like you said, when they're— oftentimes nurses know where the litigation is going to be because there was an event. Oftentimes it's a code, right? And then I've seen up on the big screen. So when I say big screen, I mean in a courtroom. The no checkbox on bagging, no checkbox on compressions. We're all standing there. We've all seen the scene. Of course they are. But now it's 5 years later, and now, you know, risk management's having to be called to talk about what you did or did not document. And you can't say that you're bagging. Show us. Where's the video? Where's the video of it? Yeah, you didn't document it, so show us what you're doing. Patient died. But you see how it just becomes theater? And now again, they're playing into— you couldn't even document. Wow. Yeah. You see, it's, it's, it's— yeah. So code—

It's important. It's important stuff. And I think the important, like, the thing to hit home about this is I think it's not, not to scare people, not to scare nurses, but just, just to be aware, you know, just to be like, these things are real. And I think a lot, you know, a lot of people are like, oh, it won't happen to me. Or we kind of just ignore it, turn a blind eye until it does. And then you're like, shit, like, I, you know, I've— I didn't prepare like maybe, maybe I should have. And just like those little things that have happened me just have made me hyper-aware of just like things that I'm documenting because I've seen, you know, they sent me, if I remember this correctly, like they did send me like my documentation and you just said that when you, when you're going back and looking at all that, you're like, oh, like, like this is, you know, I can see how when you're looking at this almost years removed, it's like you, you really, if you're not spot on with your documentation, like any narrative can kind of be written up about like what happened, even if you know. What actually was happening.

You want to give the narrative to the expert nurse. I call this the woof nurse, because if you spell out the narrative, then they're gonna say you met the standard of care. So that's a gift to whomever is going to opine on your conduct. Because again, I've looked at plenty of cases, there was no nursing negligence, therefore there was never a report. There could never be anything generated because there was no nursing negligence. Because when I looked at documentation, it reflected the care that was provided. Yeah, yeah.

Wow. Okay, so then, uh, the next one is, is charting late dangerous or can it actually like help you?

So late, give me context. What do you mean?

Like, I guess what's the— is this— I don't know if this is like— is this like facility dependent or is this, um, in general? Like how— because sometimes like I know people would come back the next shift and document on what happened yesterday if they had like forgot something or they had a crazy shift in the ICU or something. So they're like, I'm back tomorrow, I'll just Like, document it when I get back tomorrow.

Okay, so great point. And then you get in a car accident, you don't make it, you don't— you know what I mean? So that's point number 1. Number 2, um, you should really try to document as close to the event as possible when you are going to document. And there's nothing wrong— to your point, you forget something, you're taking care of the patient and you're like, oh my gosh, I forgot this— you just have to make sure that you're writing late entry And then whatever it is in a factual manner, try to just keep it, you know, just that you forgot, you know, don't go into great, you know, crazy detail. But then follow the policy, has something that will guide you as it pertains to late entries in the medical record. Does that make sense?

Yeah, yeah, yeah.

But there's nothing wrong with that. The only problem is if someone has a bad outcome, And then you decide two weeks later after legal counsel gets a hold of you to go back into the medical record and chart.

That's a no-no. Duck's bath. Yeah, that's bad. Yeah, yeah, that's a bad one. How do you feel? An audit trail. Yeah, that yeah, that one would yeah stand out as like a big red flag to me. How do you feel about like quoting like direct quotes like doctor states da da da da?

I'm about that and quoting what the patient said again. You're painting a picture of the care. that was provided. And not that you're trying to be— you don't want to be egregious, but—

Right.

You want to paint a picture because if the patient's being hostile, if the patient— that does help to paint a picture. The patient's cussing at you, all you're going to just say in a factual manner, patient states. And then someone will read that and be like, okay, that does paint a picture. Now, as it pertains to the doctor, if the doctor states something— but again, these are our coworkers, right?

Yeah.

We have to be careful with that, but we can't not just write, I told the doctor. If the doctor's non-responsive, then we call a rapid, we call a code, we escalate. So I only say that because I have seen nurses write, well, no, I wrote, I let the doctor know, and then the patient coded. Like, that was it.

Yeah.

So you're not off the hook by saying doctor, by quoting the doctor. But I am about— because it's part of the plan of care, because what if another provider, doctor, you, you know, I'm pregnant and I drop off, you know, I'm like, oh God, I got to bounce out.

Yeah.

And then you come and you can see in the medical record, oh, she did call Dr. Bob, she called Dr. Smith. So just in a factual, professional manner, you don't want to put a bad light on anyone. You just want to keep things factual. Because again, now imagine it is in a court of law. You have people from the grocery store that could be judging You and other providers. You just want to keep it to— I promise you, in your factual quoting, it will look as egregious as it's supposed to.

Yeah, yeah, yeah. So just really like what's really, really necessary. I think Epic actually lays that out pretty well as far as like communications. You know, it's like, who did you contact? How did you contact them? What did they say? And what was like— what did they want? Like, were there verbal orders? No new orders? Um, you know, things like that. So I think just checking those boxes and making sure, yeah, if there was a direct quote that's pertinent, that matters. Like, you can free text that stuff. Yeah, it's a lot. So yeah, so I think everything to kind of tie everything in, I think what you do is so important. I think we we really obviously need people like you with this knowledge because like this is stuff that's like way over my head as far as like the legal aspect goes. So I think it's it's a good you're a great resource for nurses to have if these things happen to them. If they get that that terrible phone call we all fear, I think it's it's great for as many nurses to know that like there's resources like you available. I know you have your website. If you don't mind just telling us where we can find you. And how nurses get into contact with you if they need help?

Sure. So I don't— it's nothing crazy. Advocates for Nurses, Advocates for Nurses on all the platforms. You can go to my website. I have free resources. Any nurse can book time with me. Lawyers I've had reach out to me. Healthcare systems, schools have reached out to me. So I would rather have it given in school, right? Because again, a little Scared Straight. I know I'm aging myself, but if you know some of this stuff, I think intertwined in school, then you're less likely to do some stuff. So Advocates for Nurses, I'm on every social media platform. And I don't know if you know, but one of the number one reasons why— and again, trigger warning— um, someone will— a nurse will attempt suicide is a border nursing complaint.

Really? Wow.

So often just providing them with resources. So I have resources. You are never alone. Never alone.

I love that.

Any nurse can reach out.

Yeah, this job, this job is so stressful from every angle. And then if you have, if you have the, the highest, the Board of Nursing also kind of coming down on you, it's just like, you're just like, there's— you, you really have to protect yourself in every single aspect of this, of this job. So what you do is super important. So thank you, Maggie.

Well, thank you for inviting me on and let me share my message, because again, I can create all this stuff and do all this stuff, but to your point, if people don't know that I have this stuff— because I have had nurses come back to me, I mean, Redonda tells You know, I mean, some of the stuff that I talk about that I do, I've had plenty of other nurses. It's the educational piece of it. Lawyers have told me, you know, after my client spoke to you, I felt like I had a better conversation. They had a better understanding. Their anxiety was a lot less because oftentimes they couldn't even communicate with the lawyer because they couldn't stop crying.

Yeah.

Because they were just— didn't understand what was happening.

That's great.

And they could actually have a conversation with the lawyer. develop out a plan because they had some educational resources.

Yeah, yeah, it's— yeah, it's scary stuff. So it's— I guess, like I said, I think like the best word for, for me is just like, it's, it's just so important. And there's, um, it's a lot of it, you know, a lot of information that many of us have no idea about. So, so thank you.

You're welcome.

From the bottom of my heart, I wanted to thank you for being here at Club Nurse. I hope you something valuable from today's episode. And if you did, remember to share this episode with someone that you love. Follow me on socials @NurseDaddies or @ColtonLord17, and be sure to follow nurse.org to stay informed with all of the hottest healthcare topics. Until next time, take care of yourself the way you take care of everyone else. Love ya. Bye.