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Ethical and Professional Conduct 20-397551 Back to Course Index

                                                       Ethical and Professional Conduct


Should I?…What will happen?…What would you do?…What will people think?…What is right?…Who will know?…


In the broadest sense, ethics are the principles that guide an individual, group, or profession in conduct. Although health care professionals frequently do make independent decisions regarding patient care, they are still responsible to the profession of patient care, as a whole, in how those decisions are made. From the earliest concept of caring for someone who is sick or injured, the proper behavior and conduct of a medical professional have been closely scrutinized.


This continuing education course will discuss the basic principles of ethics as they apply to allied health professionals. An overview of the terminology used in medical ethics texts is explored.

We will explore:

– The difference between morality and ethics

– Normative ethics, Metaethics, and Applied ethics

– Medical issues that would be difficult to solve with virtue-oriented reasoning

  • Basic terms used in the discussion of ethics
  • Examples of situations the pose challenging ethical decisions
  • Ethical codes for a variety of allied health professionals
  • Solving ethical issues

– The American Hospital Associations The Patient Care Partnership


Defining Ethics 

Many of us confuse morality and ethics when we attempt to come up with a definition for ethics. Ethics is defined as a particular system of principles and rules concerning duty. As described by Ruth Purtilio, Ph.D., in Ethical Dimensions in Health Professions, morality is concerned with relations between people and how ultimately, they can live in peace and harmony. Morality is defined as a system of ideas of right and wrong conduct.

The difference between ethics and morals can seem somewhat arbitrary to many, but there is a basic, albeit subtle, difference. Morals define personal character, while ethics stress a social system in which those morals are applied. In other words, ethics point to standards or codes of behavior expected by the group to which the individual belongs.

When considering the difference between ethics and morals, it may be helpful to consider a criminal defense lawyer. Though the lawyer’s personal moral code likely finds murder immoral and reprehensible, ethics demand the accused client be defended as vigorously as possible.


History of the Nursing Code of Ethics

The Code of Ethics for Nurses establishes ethical principles in nursing. Far more than just words on paper, the code is nursing’s north star. It governs how nurses behave during the vulnerable moments when patients place their trust, their care, and perhaps even life and death decisions into their hands.

Established by the American Nurses Association (ANA), the Code of Ethics for Nurses “informs every aspect of the nurse’s life.” As such, the ANA Code of Ethics for Nurses is the profession’s non-negotiable standard.

It’s also a dynamic document and one that has responded over time to healthcare, technological and social changes.

The origins of nursing ethics reach back to the late 1800s — a far different era when nurses weren’t viewed as valued members of a healthcare team as they are today. And concepts like justice in nursing? Well, let’s just say that wasn’t a thing back then.

Times have changed.

Formally adopted by the ANA in 1950, the Code of Ethics is revised approximately every decade to keep pace with advances in healthcare and technology, greater awareness of global health, greater inclusivity, and the expansion of nursing into advanced practice roles, such as the family nurse practitioner. Today, there are four principles of nursing ethics and nine provisions that guide practice.


Terminology of Health Care Ethics

In every study regarding health care ethics, you will encounter some pretty lofty-sounding terms like we just explored above. How do these and other frequently used ethics terms relate to allied health professions? The following will explore the seven principles that are considered to be the foundation of health care ethics.

Autonomy is the individual’s right to make decisions, free from deceit, duress, constraint, or coercion. Autonomy works when the patient is able to make decisions based on adequate provision of information and intellectual competence. The individual must also possess the ability to act on his/her decisions. Without this power, autonomy is futile. What good is it to make a decision, but not be able to carry out the actions associated with that decision? This principle raises important questions related to informed consent, competence, and an individual’s right to refuse treatment.

Competence is a challenging determination in health care decisions. Who has the right to determine a patient’s competency in deciding his or her own course of diagnosis and treatment? Health Care professionals may or may not be informed of the patient’s legal competency status.

Veracity refers to the legal principle that states that a health professional should be honest and give full disclosure to the patient, abstain from misrepresentation or deceit, and report known lapses of the standards of care to the proper agencies. This is very important, as the patient and the caregiver must be truthful for the outcome to be positive.

Beneficence is the professional duty to do or produce good. “good” is meant as the performance of acts of kindness and charity. “Doing good” is considered virtuous conduct. Ultimately, beneficence is the duty to do more good than harm through public health actions because, in practice, no action in public health will have exclusively beneficial effects.

Nonmaleficence derives from the ancient maxim primum non nocere, which, translated from the Latin, means “first, do no harm.”

Both beneficence and nonmaleficence have become very complicated ethical principles because of the rapid technological developments in health care. Many treatments that benefit patients also have adverse effects that may harm the patient. Health care professionals are constantly weighing the pros and cons of the treatment they choose for their patients. We are always trying to utilize therapies that have maximum benefits and minimal risk.

Beneficence and nonmaleficence are also at the heart of the debate over physician-assisted suicide and euthanasia, as well as many other issues. Who decides what will help a terminally ill patient in extreme pain? How can we make sure that patients requesting assistance in committing suicide are competent? Are individuals in extreme pain able to make rational decisions? No doubt, physician-assisted suicide, euthanasia, abortion, cloning, and many other ethical topics will continue to be debated in our society for many years to come, if not forever.

Confidentiality refers to the authorized or unauthorized disclosure of information. Patients have the right to expect that their health information will not be disclosed without their permission. Health care professionals should only discuss a patient’s case with other practitioners when they are in need of a consultation. These conversations should take place in a private setting and health care providers should maintain a professional demeanor during these conferences. Discussing a patient in the elevator, in the cafeteria, or outside of work may result in a breach of confidentiality, a violation of trust.

More and more health information is being kept and shared online. Many health care consumers are concerned about maintaining the confidentiality of their medical records largely due to the use of computers in health care. The amount of documentation required by insurance companies and managed care companies, so they can review the data to ensure that claims are based on medical necessities can jeopardize confidentiality. Where is all of this information stored, who has access to it and how much can we protect patient data in the computer and internet age? Some of these questions have been addressed by a series of federal regulations designed to protect patient privacy and the confidentiality of their medical records. The law designed to protect this information is known as the Health Insurance Portability and Accountability Act of 1996 or HIPAA.

-HIPAA was first developed to make sure that people could not lose their medical coverage when they changed jobs even if they had a pre-existing medical condition. As with many federal laws, the bill grew larger and larger. HIPAA today affects almost all health care providers or anyone who is employed anywhere where patient information may be located, including hospitals, clinics, radiologists, and more.

The first goal of the law is to improve the portability and continuity of an individual’s health-exempt pre-existing conditions as long as the insured’s previous health coverage has not lapsed more than 60 days before any new plan takes effect. This part of the legislation became effective in late 1996.

The second goal is to improve healthcare’s administrative efficiency and effectiveness by standardizing electronic transaction processes and setting standards for the major healthcare code sets. The regulations also define and establish standards and national databases for health care providers, health plans, and employers.

The third goal of HIPAA is to strengthen the health care industry’s ability to combat waste and fraud while protecting and securing patient confidentiality. You are surrounded by patient data information and it is your responsibility to keep it private and confidential. If not, your employer and you can face financial and criminal penalties.


How does the HIPAA Privacy Rule Affect You?

The HIPAA Privacy Rule, the first major HIPAA regulation, became effective      

April 14, 2003. It requires that almost all healthcare providers who file claims for reimbursement meet this required date or face significant fines and other penalties.

As the original HIPAA regulations to assure patient insurance portability were developing, congress urged healthcare organizations to become more

efficient through computerization. But, before doing so, they expanded the

regulations to make sure that legal safeguards were added to protect patient information from prying eyes. This is the basis of the privacy rule.


A Covered Entity

Basically, any organization covered by HIPAAs regulations is a Covered

Entity. You see HIPAA regulations cover much more than healthcare

providers. In fact, all health plans and payers of healthcare services are also covered by HIPAA.

Covered Entities include hospitals, clinics, dentists, laboratories, mental health providers, medical imaging services, and just about everyone that delivers any form of health care then files a claim electronically and gets paid or reimbursed for their services.

HIPAA is quite serious about these regulations. The penalties for violating the Privacy Rule can range from a simple fine all the way up to 10 years in jail plus a $250,000 fine.


Protected Health Information

HIPAA Privacy requirements are based on the concept of Protected Health Information or PHI. This is medical information that contains any data element that can be used to link a past, present or future medical condition to an individual. The regulation lists 19 such elements and includes items such as a patient’s name, address, birth date, telephone or fax number, employer, license number, etc.


Do You Know Your Organizations HIPAAs Policies and Procedures?

Section 164.530 of the Privacy regulation makes it clear that a covered entity must implement policies and procedures with respect to PHI (Personal Health Information) that are designed to comply with the standards. In other words, your organization must have a set of written policies and procedures when it comes to protecting PHI (Personal Health Information) and you need to read them.


Justice is the sixth ethical term of discussion and consists of the concepts of fairness and entitlements. Health care is a limited resource. The concept of distributing health care across the population fairly is referred to as distributive justice. Many issues affect this distribution, such as insurance benefits, wealth, and location. As we all know, there are many citizens who do not have health insurance, and as a result, do not receive the same amount or quality of health care as those with benefits. Rural areas of the U.S. do not have the same health care resources as an urban setting. Large teaching hospitals are located in large cities, not out in the rural sections of the country. Another issue that is related to the concept of justice and how to fairly distribute health care is organ and tissue transplantation. There are a limited number of organs available for transplant. Who will receive the organ that they so desperately need? How do we establish a waiting list for organs? This is a very complex issue, and experts in this field have worked very hard to create a fair system for the distribution of organs.


Role fidelity is the final principle that contributes to the foundation of health care ethics. Role fidelity refers to the scopes of practice of the many allied health professions. We each have a specialty and need to practice within our knowledge and experience base.



Patient Rights 

Patients are health care consumers. They are more knowledgeable about their rights than in the past. As allied health professionals, we should be familiar with patient rights and abide by them in our everyday practice.

In 2003, the American Hospital Association replaced its aging Patient Bill of Rights with a new series of guidelines on how patients are to be treated while in the health care system. These guidelines are available as a brochure, entitled The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities.


Professional Codes

Codes of ethics are documents created by professional organizations to provide their members with values and standards of behavior for their discipline. 

 Provisions of the Code of Ethics for Nurses

In addition to the high-level ethical principles in nursing described above, nurses must abide by a Code of Ethics.

From patient dignity and confidentiality to a safe environment and work setting, nurses are to abide by the nine provisions of the Nursing Code of Ethics, according to the American Nurses Association.


  • Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth and unique attributes of every person.


  • Provision 2: The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.


  • Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.


  • Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.


  • Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence and continue personal and professional growth.


  • Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality healthcare.


  • Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.


  • Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy and reduce health disparities.


  • Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession and integrate principles of social justice into nursing and health policy.


Solving Ethical Problems 

The first step in analyzing moral issues is obvious but not always easy: Get the facts. Some moral issues create controversies simply because we do not bother to check the facts. This first step, although obvious, is also among the most important and the most frequently overlooked.

But having the facts is not enough. Facts by themselves only tell us what is; they do not tell us what ought to be. In addition to getting the facts, resolving an ethical issue also requires an appeal to values. The following are a few approaches to solving ethical issues created by philosophers.


The Utilitarian Approach

Utilitarianism was conceived in the 19th century to produce the greatest balance of good over evil.

To analyze an issue using the utilitarian approach, we first identify the various courses of action available to us. Second, we ask who will be affected by each action and what benefits or harms will be derived from each. And third, we choose the action that will produce the greatest benefits and the least harm. The ethical action is the one that provides the greatest good for the greatest number.

The Rights Approach
According to this approach, what makes human beings different from mere things is that people have dignity based on their ability to choose freely what they will do with their lives, and they have a fundamental moral right to have these choices respected. People are not objects to be manipulated; it is a violation of human dignity to use people in ways they do not freely choose.

Of course, many different, but related, rights exist besides this basic one. These other rights (an incomplete list below) can be thought of as different aspects of the basic right to be treated as we choose.

  • The right to the truth: We have a right to be told the truth and to be informed about matters that significantly affect our choices.
  • The right of privacy: We have the right to do, believe, and say whatever we choose in our personal lives so long as we do not violate the rights of others.
  • The right not to be injured: We have the right not to be harmed or injured unless we freely and knowingly do something to deserve punishment or we freely and knowingly choose to risk such injuries.
  • The right to what is agreed: We have a right to what has been promised by those with whom we have freely entered into a contract or agreement.

In deciding whether an action is moral or immoral using this approach, then, we must ask, does the action respect the moral rights of everyone? Actions are wrong to the extent that they violate the rights of individuals; the more serious the violation, the more wrongful the action.


The Fairness or Justice Approach
The basic moral question in this approach is: How fair is an action? Does it treat everyone in the same way, or does it show favoritism and discrimination?


The Common-Good Approach
This approach to ethics assumes a society comprising individuals whose own good is inextricably linked to the good of the community. Community members are bound by the pursuit of common values and goals.

In this approach, we focus on ensuring that the social policies, social systems, institutions, and environments on which we depend are beneficial to all. Examples of goods common to all include affordable health care, effective public safety, peace among nations, a just legal system, and an unpolluted environment.

Appeals to the common good urge us to view ourselves as members of the same community, reflecting on broad questions concerning the kind of society we want to become and how we are to achieve that society. While respecting and valuing the freedom of individuals to pursue their own goals, the common-good approach challenges us also to recognize and further those goals we share in common.


What do these mean in application?
These approaches suggest that once we have ascertained the facts, we should ask ourselves five questions when trying to resolve a moral issue:

  • What benefits and what harms will each course of action produce, and which alternative will lead to the best overall consequences?
  • What moral rights do the affected parties have, and which course of action best respects those rights?
  • Which course of action treats everyone the same, except where there is a morally justifiable reason not to, and does not show favoritism or discrimination?
  • Which course of action advances the common good?
  • Which course of action develops moral virtues?



Nursing  Documentation

People have been jotting things down for a very long time. As a matter of fact, research has traced the origin of the written word to Ancient Greece, the Renaissance, and the mid-ninth Century. However, the discipline of technical communication is seen as growing out of the need for accurate and technology-based documentation required by the military, industry, healthcare, and other disciplines. Technical communication is the process whereby usable information is communicated through written or spoken information about a specific domain for an intended audience. The information is deemed usable when the intended audience is able to act upon or make a decision based on its content. Consequently, the process of developing information products begins by ensuring that the nature of the audience and their need for information is clearly identified. Technical communication is considered a professional task for which organizations either hire specialized employees or outsource their needs to communication firms. However, in the nursing profession, it is incorporated into the daily tasks of professional nurses.

Nursing has a distinguished history of concern for the welfare of the sick, the injured, and others that are in need of care as well as social justice. One of the essential tasks that must be performed to ensure an equitable outcome is a professional and consistent approach to the documentation of patient care and medical history. When we look at a continuum of care that spans several days, weeks, or months we realize how critical it is for the next shift to know precisely what and when medications were administered and medical procedures performed. The documentation should always include the date, time, event, and outcome data as well as any minor details that are relevant to patient care.


Nursing Responsibilities with Documentation

The nurse’s primary responsibility is to provide professional patient care and to promote welfare over all other interests. Nurses are educated and trained to encourage interactions in ways that foster the interest and welfare of patients and promote the development of a healthy nurse-patient relationship. Nurses actively attempt to understand the special needs of each patient as well as the diverse conditions and backgrounds of the patients they serve (this includes belief systems, morals, languages, and ethics). Nurses also explore their own background and beliefs and how these may affect their values about the nursing processes and their own commitment to excellence and professionalism.

Generating and maintaining accurate, legible, and professional medical records are one of the most important functions of the nursing profession. Because the attending nurse often has more direct interaction with the patient than any other caregiver, they are required to maintain patient records that are necessary for rendering professional services to their patients and as required by laws, regulations, and/or agency or institution procedures. Nurses are required to include sufficient and timely documentation in their patient’s records to facilitate the delivery and continuity of needed services. Nurses are required to take reasonable steps to ensure that the information contained in their records accurately reflects patient progress and services provided. If errors are made in patient records, nurses take steps to properly note the correction of such errors according to agency or institutional policies.

 Charting Legal Considerations

The intent of this section is to provide nurses with information about the laws and standards governing nursing documentation. This section also addresses the legal basics for appropriate documentation as well as the consequences resulting from failure to follow proper procedures. This section will enable the nurse to:

  • Understand negligence as related to patient records.
  • Describe significant characteristics of legally credible charting.
  • Describe typical charting practices that can lead to legal problems.

  In the past, nurses were less likely to be involved in negligence lawsuits (than physicians); however, as the nursing responsibilities have increased they have become more susceptible to negligence lawsuits. As one might expect, many of the lawsuits are related to improper or inadequacies associated with the content of patient records. As a matter of fact, it’s likely that you or one of your nursing colleagues will become involved in a professional negligence lawsuit, or in you will probably know of another nurse who has been or is being sued for negligence.

The nurse must recognize that the patient’s chart is a legal document that describes the care provided by you and other caregivers. Consequently, your documentation must provide a complete and accurate accounting of your patient’s condition and the care you provided. If you are asked to testify in legal action, you may need to recall details that occurred months or even years ago. Without a complete, accurate, and legible medical record, you may be unable to defend yourself against allegations of improper care. Effective documentation can be your best defense if you’re named in a lawsuit and may even help in getting the lawsuit dismissed.

Most lawsuits involving nurses are civil cases that attempt to prove that a nurse’s negligent care resulted in injury to a patient. As noted previously, negligence occurs when there is a failure to provide a patient with the standard of care that a reasonably prudent nurse would exercise under the same or similar circumstances. The following conditions must exist in order to prove negligence:

  •        When someone acts in a careless way and causes an injury to another person, under the legal principle of “negligence” the careless person will be legally liable for any resulting harm. This basis for assessing and determining fault is utilized in most disputes involving an accident or injury, during informal settlement talks, and up through a trial in a personal injury lawsuit.
  •        In negligence claims the plaintiff (the person injured) tries to show that the defendant (the person supposedly at fault): a) Owed a legal duty of care to the plaintiff under the circumstances; and b) Failed to fulfill (“breached”) that legal duty through conduct or action (this can include a failure to act); and c) Caused an accident or injury involving the plaintiff, and d) Harmed or injured the plaintiff as a result. 

Expressed in nursing terms, the patient’s attorney must prove the following elements for a valid negligence case (to prove negligence on the part of the nurse: a) Nurse had a duty to provide care and to follow an established and acceptable standard of care. b) Nurse failed to meet the standard of care. c) Nurses failure to perform to an acceptable standard of care caused the patients injuries. d) Patient suffered damages as a result of the nurse’s negligent actions.

If you face an allegation of negligence, your documentation can make or break your case. Your contention that you provided appropriate care is significantly weakened if you didn’t take the time to document your actions or if your documentation doesn’t clearly show that you met the standard of care. Without a written, legible record you must rely on your ability as a witness to convince a judge or jury that you gave appropriate care despite your failure to properly document the care.  This is a difficult situation as one must overcome the apparent lack of professionalism (inadequate or improper documentation) and attempt to convince the court the work was done satisfactorily is a very difficult sell. Again, the old axiom of if it’s not documented, it never happened comes into play. Let me simply say that all nurses need to avoid being put on the legal hot seat if at all possible.

Arguments such as not enough time, too many patients, higher priority work, and similar reasons generally have little or no influence on the court. Remember the patient’s attorney will use documentation to try to prove that the standard of care was breached; consequently, gold standard number one for every nurse should be to consistently generate complete and accurate medical records, as they are crucial to proving that you met the standard of care.


The content and control of medical records must comply with acceptable practices of the nursing industry and also meet the requirements of state law. Nursing documentation is also influenced by professional organizations such as the Joint Commission and the American Nursing Association (ANA). The Joint Commission covers a broad set of requirements that govern accreditation as well as Quality and Patient Safety. The ANA standards require that documentation reflect the treatment regime and that it should be ongoing and accessible to all members of the healthcare team. ANA standards generally reflect the industry consensus; consequently, they carry a great deal of weight in the court. It follows that the legal system has helped nurses know what must be included in patient care documentation to be considered accurate and appropriate.

Laws or administrative rules in each state further outline documentation issues, such as handling of records, falsification of records, and confidentiality. Regardless of your work setting or nursing specialty, you must document care based upon the requirements of your state’s Nurse Practice Act. It is left to the reader to research the requirements of the state board (contact the National Council of State Boards of Nursing) in your particular state and to adhere to those requirements.

It is also mandatory that nurses follow documentation policies that have been established by their hospital or other employer. As noted previously, most healthcare providers require policies and procedures to reflect the requirements of state law, professional nursing standards, and Joint Commission requirements. For example, your hospital’s policies should provide the methodology as to how documentation should be done, who is responsible for charting each part of a patient’s record, and what charting techniques and procedures are acceptable. However, if your hospital’s standards are less strict than those of your Nurse Practice Act, you must adhere to the higher standard.

Effective Documentation  

One thought that should never be very far from a nurse’s mind is the old axiom: If it wasn’t documented, it wasn’t done. Another thought that is very important is that effective documentation should leave no question in a future reader’s mind that the patient’s condition was continuously assessed and carefully monitored and appropriate entries were made in the patient’s chart. Guidelines for effective communications/charting include items such as timely, accurate, truthful, and appropriate. Timely documentation specifically means documenting care when the care is administered (do not chart in anticipation of performing a task) or as soon as possible thereafter. Regular entries demonstrate that you are checking your patient’s condition frequently. Avoid getting into the habit of waiting until the end of your shift to document as this can result in loss of important details or loss of important information because it slipped your mind or the entry was abbreviated because you were pressed for time.

Accuracy of records relates to the facts about patient care; consequently, the chart only events you personally observe (see, hear, smell, or feel).   All entries must be legible and accurately reflect the patient’s condition. Avoid generalities and/or vague statements. For example, charting 20 cm of red blood on the bed near the left knee is more specific and informative than blood on bed linens. Avoid meaningless expressions such as patient had a good night or appears or seems.

Also, all documentation must have the following attributes:

  • Truthful and/or factual (document only what you have observed and/or administered).
  •  Appropriate (include only information that you would be comfortable with if it was exposed during a legal matter)
  •  Uniformity and consistently (adhere to your hospital’s documentation policies about issues such as late entries, legible charting, record confidentiality, standard abbreviations, consigning, and patient refusal of treatment.
  •  Safety (document any safety precautions you implement, such as using restraints).
  •  Keep record professional (avoid personal comments related to peers and/or references to inadequate care). These issues should be taken to your supervisor, as they don’t fit in the patient’s record.

Patient medical records may not be altered once litigation has started. No information should be added or deleted (by anyone, nurse, colleague, staff, supervisor, or others) as experts can determine when various entries were made and which ones were altered.   If you suspect that another healthcare professional has made illegal changes to a patient’s chart, notify your nursing supervisor immediately. Tampering/altering a patient’s chart is illegal and can cause the patient’s record to be inadmissible in court. Also, a nurse can be charged with falsification of records and/or fraudulent care if care was documented that was not provided. The plan of care is the primary component that can be documented before it is done.

Your legal risk increases if you fail to clearly describe situations that are out of the norm and/or that you consistently use high-risk abbreviations. Extra effort should be taken to describe in detail any and all situations that are out of the ordinary or if an unexpected outcome is observed. As for abbreviations, the Joint Commission identified improves the effectiveness of communications among caregivers as one of its initiatives in January 2004. This along with other initiatives led to the following Do Not Use list of abbreviations:


Do Not Use

Potential Problem

Use Instead

U (unit)

Mistaken for O (zero), the Number 4 (four) or cc

Write unit

IU (International Unit)

Mistaken as IV (Intravenous) or the number 10 (ten)

Write International Unit

Q.D., QD, q.d., (daily)
Q.O.D., QOD, q.o.d., qod
   (Every other day)

Mistaken for each other,
Period after the Q mistaken for I, and the O mistaken for I

Write daily
Write every other day

Trailing zero (X.0 mg)*
Lack of leading zero (.X mg)

Decimal point is missed

Write X mg
Write 0.X mg

MS, MSO4 and MgSO4

Can mean morphine sulfate or Magnesium Sulfate
Confused for one another

Write morphine sulfate
Write magnesium sulfate

Additional Abbreviations, Acronyms and Symbols
(For possible future inclusion in the official Do Not Use list)

> (greater than)
< (less than)

Misinterpreted as the number
7 (seven) or the letter L
Confused for one another

Write greater than
Write less than

Abbreviations for drug names

Misinterpreted due to similar abbreviations for multiple drugs

Write drug name in full

Apothecary units

Unfamiliar to many practitioners
Confused with metric units

Use metric units


Mistaken for the number 2 (two)

Write at


Mistaken for U (units) when poorly written

Write ml or milliliters


Mistaken for mg (milligrams)
Resulting in one thousand-fold overdose

Write mcg or micrograns


It is strongly recommended that the aforementioned Do Not Use the list of abbreviations and symbols be avoided in all patient-related medical records.

Another practice that can lead to disharmony in the courtroom is to describe a patient’s behavior as uncooperative, difficult, or manipulative or refer to the patient in a sarcastic manner. The prosecuting attorney may challenge the nurse’s professionalism by showing the nurse did not respect or value the patient. The patient’s behaviors should be described in a factual and impartial manner.

Sentinel Events

The Joint Commission refers to a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury typically includes loss of limb or function. The phrase or the risk thereof includes any process variation for which recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentinel because they signal the need for immediate investigation and response. Sentinel events generally constitute crises and require a rapid response from all caregivers; consequently, they are generally very difficult to manage in that a nurse is faced with an emergency situation with a patient and is still required to maintain all other functions such as documentation. It is not surprising that these events are often the basis for legal actions against caregivers using poor communication and documentation as the catalyst to spring the lawsuit. Needless to say, it’s extremely important to document care as it is provided especially during an emergency situation.

During a sentinel event, it is fairly common for nurses to be held liable for failure to observe and report when a patient’s condition undergoes a rapid change. If these changes are not reported immediately it is an indication of a lack of observation on the part of the nurse. Accusations of failure to adequately observe and monitor can be substantially countered by accurate and detailed documentation.

Another of the more common legal issues arises due to a nurse’s failure to properly notify the physician about changes in the patient’s condition. These situations are often serious and may result in the death or disability of the patient. A nurse always has the responsibility to intervene on behalf of their patient and to take whatever action is appropriate. The intervention often involves contacting the physician followed by carrying out whatever therapy the doctor prescribes. In many cases, your legal obligation goes beyond carrying out prescribed treatment. For example, if in your professional judgment you consider the physician’s orders to place a patient in jeopardy, you must intervene on behalf of the patient and clarify the treatment plan with the physician. Some recent malpractice cases have hinged on whether the nurse was persistent enough in an attempt to notify the physician or to convince him or her of the seriousness of the situation. Nurses who fail to continue to question inappropriate orders by contacting a nursing supervisor or going up the chain of command can be held liable for failure to intervene because the intervention was below what is expected of them as patient advocates.

If a physician must be notified, you must be able to communicate essential information in a clear and concise manner. Communication is generally by phone and this type of communication is generally less effective than face-to-face as the nonverbal clues are eliminated. Consequently, when you are communicating via the phone the information must be presented in a manner that will enable the physician to develop a visual image of the situation. On weekends, you may talk with someone other than the primary care physician; consequently, it is essential that you provide background information before describing the problem.

You must document each time you phone a physician, even if no one answers. If you have a conversation then document the details including the therapy prescribed. Also, document the physician spoken to by name rather than referring to him or her as the MD or the doctor. If, in your professional opinion, you don’t believe the physician is responding appropriately, you’ll need as much supporting documentation as you can get as a legal safeguard. Note specifically the details you reported, time of contact, time new orders or no orders were received, and additional actions you take. If you don’t note the time you called, allegations could be made later that you failed to obtain timely medical treatment for the patient. Always note in the chart the specific change in the patient’s condition or diagnostic test result that prompted your call to the physician. If you’re reporting a crucial lab result, such as elevated blood pressure, but don’t receive an order for intervention, be sure to verify with the doctor that he or she doesn’t want to give an order. Your documentation should note: Dr. Brown was notified of high blood pressure (155/95). No orders received.

Minimizing legal risks is important in today’s healthcare climate especially when one recognizes that we have a proactive legal system. Comprehensive documentation that reflects the treatment modalities, as well as the nursing process, is essential for survival in the healthcare industry today. Remember that patients’ records and what they contain are the single most important tool available to a nurse facing a charge of negligence. As stated previously, legally credible and legible documentation provides a written record of the care your patient received and evidence that you met an acceptable standard of care.

The following actions are recommended to provide your patient with optimum care while protecting yourself and your employer from legal action:

  • Adhere to your state’s nurse practice act.
  • Dedicate yourself to following professional standards for documentation at all times. Ensure that all documentation is accurate, timely, and legible and meets or exceeds the standard of care that has been established by your colleagues and peers.
  • Adhere to your hospital’s policies and procedures and seek assistance from your supervisor as required.

Charting Mistakes to Avoid

The following charting mistakes are fairly common and have led to numerous lawsuits:

Improper drug dosage recorded: May lead to over or under dose in subsequent applications.

Failure to record disease and/or allergies:

For example, if a patient is allergic to a specific medication then the caregiver needs to be informed about his or her condition. If information such as this is not compiled and transmitted to appropriate caregivers then you may be subject to a negligence lawsuit. Some hospitals alert other staff members to drug allergies by putting a label on the outside of the patient’s chart.

Nursing actions not properly recorded: All interventions must be properly recorded on the patient’s chart. The usual excuse for not charting is insufficient time. At high-stress times this may be a valid reason; however, the court does generally not accept it.

Failure to record medications when given: Improper recording can result in either an underdose or overdose.

Wrong chart used to record data: avoid confusion by always verifying patient/chart comparability.

Failure to document a discontinued medication: Crosscheck the medication against the physician’s order.

Failure to document a patient’s reaction to a medication: Monitor the patient often to detect any negative reaction to any mediation. Alert the doctor immediately if an unexpected outcome occurs.

Transcriptions errors: Verify prior to use any time you are unsure about either the medication or dosage.

Writing illegible records: Print if your handwriting is poor; Avoid abbreviations that aren’t approved by the hospital; document sufficiently to show the patient was cared for and that you met the standard of care.


Every individual and/or organization needs a plan to monitor the quality of his or her output. The following is recommended for nurses with respect to their documentation:

Self-audits: Randomly choose patient records that you have generated. Review the records to see if they are complete, contain the proper information, and are legible. If you struggle to understand the record it would be difficult to defend in court.

Peer reviews: Essentially the same as a self-audit except peers are looking at the records. If this group has difficulty understandings the record then it could be troublesome in court.

If problems are identified then corrective actions should be taken immediately. The team goal should be to establish an acceptable standard of care in your hospital.