The Critical Importance of Documentation
It's all in the details and sometimes, what isn't said, speaks volumes.
Linda Acker FNP
8/25/2025
In the world of personal injury and medical malpractice, every detail matters. A recent case study published in American Nurse highlights the devastating consequences of incomplete documentation and failure to meet the standard of care, resulting in the suspension and probation of a Nurse Practitioner's license.
The article describes the case of a 10-month-old infant who died from complications related to RSV after being treated for a cough. The State Board of Nursing (SBON) investigated the case and found the nurse practitioner guilty of gross negligence.
Documentation is a Cornerstone: The NP's license was disciplined not just for the outcome, but for a "blatant disregard for the minimal standards of documentation." This highlights the legal significance of thorough and accurate charting.
Deviation from Standard of Care: The board found an "extreme departure from the standard of care," specifically the failure to perform and document a complete respiratory assessment. This nurse practitioner cited that the day was very busy but in nursing we are taught "if it isn't documented, it wasn't done"
Clinical Significance: The case illustrates how seemingly small details—like failing to chart a heart rate or oxygen saturation—can have huge clinical significance and form the basis of a strong legal argument.
This case study is a powerful reminder of how in an depth medical record review can uncover key evidence. It reinforces the importance of partnering with a Legal Nurse Consultant to identify crucial gaps in records and build a strong case.