Documentation is vital to the medical record and is subject to intense investigation and scrutiny if you or your employer are sued. It is very important for you to document (write) in the medical record accurate and descriptive chart notes. These notes should always be an accurate reflection of what happened without your opinion, emotion or judgments of the situation. Using the situation below, think about what you would write in the medical record. What would be important to include or not include in your documentation. What information would be important should a case go to court? Remember by the time a case is heard in a courtroom several years will have gone by. You will be asked to read your documentation and testify to it. The Situation (based on a true story):

You are a RN. A newborn baby girl and her mother are in the postpartum unit of the hospital. The mother calls for a nurse stating, "the baby has spit up and can't clear her mouth. She's not breathing." The nurse immediately goes to the room and picks up the newborn. She begins to use the bulb syringe provided in the newborn's bassinet to suction out the baby's mouth. Before she is finished, the nurse accidentally drops the bulb syringe onto the floor. The nurse knows it is now contaminated and should not be used but a replacement is far away down the hall. The mother picks up the bulb syringe off the floor and instructs the nurse, "use it." The nurse takes the contaminated bulb syringe from the mother and continues to suction the baby's mouth and the newborn begins to breathe again.

You need to document this event in the medical record. You know a significant rule was broken. How do you document this incident to ensure the hospital and you are protected should the mother decide to bring legal action against the hospital at a later time? Write your documentation below.