Medical Record Documentation: Legal Aspects in Neonatal Nursing

All nurses have a duty to maintain a complete and accurate recording of all care they provide in accordance with acceptable standards of care. Nurses working in specialty areas of nursing practice such as the neonatal intensive care unit are at greater risk for exposure to litigation simply by the nature of the complexities of the care required of patients. Being aware of common areas of malpractice litigation in neonatal nursing increases the awareness and recognition of potential vulnerable charting practices of nurses. Knowing the “how,” “what,” and “when” of documentation can decrease exposure to litigation by strengthening the accuracy of medical record entries; this is the nurse's best defense.