Masters v. Khuri (2004) is a case regarding a delay in treatment. Dr. Masters, the plaintiff, brought suit against Dr. Khuri, the defendant, the emergency department physician, stating that he was not intubated at an appropriate time. Since several forms of timepieces were used, it was difficult to establish a chronological sequence of events. Also noted in this case, some of the documentation was after the fact due to cardiorespiratory arrest actions and events were taking place.
The case of Chace v. Curran (2008) discusses the child, Chace was born and caused by careless delivery by Dr. Kuran. The child had suffered mental and physical disabilities due to being without oxygen for several minutes. The claim was that Dr. Curran, and another nurse had intentionally concealed records and omitted documentation about the child being deprived of oxygen during resuscitation. Consequently,
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Make sure that all communication is legible. During time sensitive situations such as codes, one person needs to be designated as the time or record keeper. Also, code sheets keep everything in a chronological order. During these situations, using the same watch is imperative. Noting exactly the name of the physician that is paged and when the page is returned is important to document. If no physician returns calls, then it is time to escalate up to the chain of command. Any EKG strips should be part of that record as well.
Avoid the use of abbreviations that The Joint Commission (2016) has required hospitals not to use. I still see nurses and physicians use some of those abbreviations. If you use hand-generated records, do not leave any blanks so that someone else can alter your documentation. Use the hospital or facility policy if there is a correction that needs to be made in the document. Do not scratch out, use liquid paper, or conceal any documentation. This makes the nurse look like you are falsifying