Documentation of Patient Care: An Often Underestimated Responsibility

See, e.g., Annas G.J. Glantz L.H. Katz B.F. , The Rights of Doctors, Nurses, and Allied Health Professionals (Avon Books, New York) (1981) at 170–92 [hereinafter referred to as Rights].

People v. Smithtown General Hosp., 402 N.Y.S.2d 318, 323-24 (N.Y. Sup. Ct. 1978).

Rights , supra note 1, at 155.

For a listing of states that belong to each category, see Rights , supra note 1, at 165, nn. 6, 7, 8.

Accreditation Manual for Hospitals, 1982 Edition (Joint Commission on Accreditation of Hospitals, Chicago) (1981) at 83–88.

Spoar v. Fudjack, 263 N.Y.S.2d 340 (N.Y. App. Div. 1965).

For a brief, cogent discussion of this point, including the distinction between nursing diagnosis and medical diagnosis, see Rights, supra note 1, at 24.

Pisel v. Stamford Hosp., 430 A.2d 1 (Conn. 1980).

Similarly, drugs that have been refused or omitted deliberately should be charted as such with a clear statement of the reasons for the refusal or omission.

See Darling v. Charlestown Community Memorial Hosp., 211 N.E.2d 253, 258 (Ill. 1965) (nurses were aware that a patient's leg cast was too tight and failed to notify hospital authorities when attending physician did nothing to alleviate the problem). For a discussion of the duty to report, see Greenlaw J.L. , Reporting Incompetent Colleagues , Nursing Law & Ethics; Part I, 1(2):4 (February 1980); Part II, Will I Be Sued for Defamation? 1(5):5 (May 1980).