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The Indefensibility of Poor Documentation

When it comes to timing of important events in a patient’s care, making the effort to note when those events occurred is well worth the minimal investment in time required.¹

This Case of the Month, “Death at Birth: A Tragedy Caused by Overwork and Undertraining,”² tells a cautionary tale of a typically joyous occasion, the birth of an infant. Errors in documentation by healthcare providers reinforce the assertion that a tragic outcome was preventable, and that care was negligent.

At midnight one evening, an expectant mother of twins and her husband presented to the labor and delivery (L&D) unit at their hospital, as scheduled, per their obstetrician’s instructions. The plan was to induce labor with Pitocin (oxytocin), monitor fetal heart rates, and safely deliver both infants vaginally. The mother’s obstetrician checked the patient into the L&D unit then went to sleep in the doctors’ lounge. He instructed the nurse and a resident physician to call him if needed.

The laboring patient was left alone for large stretches of time through the night. It was not until the 7:00 a.m. nursing shift change that the patient received close attention from the nurses. By that time, Twin A’s heart rate was slowing ominously with uterine contractions. A review of the monitor strip from the night shift showed flattening, or lack of variability, from beat to beat. Despite Twin A’s lack of reassuring heartrate, the nurse failed to initiate standard interventions to improve the infant’s condition, i.e., turning the mother, giving the mother oxygen, and giving extra fluids.

At approximately 8:15 a.m., the obstetrician decided to perform a C-section after being contacted. Twin A was still viable at this time. The C-section was not performed until after 9:00 a.m. and Twin A was delivered stillborn, with the umbilical cord wrapped tightly around her neck. Twin B was delivered safely. The autopsy for Twin A showed completely normal organs without any indication of problems, other than being undersized due to intrauterine growth restrictions.

The parents initiated a lawsuit. In evaluating this case, the plaintiffs’ attorneys focused on monitoring of the infants in utero and the accompanying documentation done by the assigned nurse in the electronic medical record (EMR). Through a legal maneuver known as a motion to compel,³ the plaintiffs’ attorneys also obtained audit trails for records of other patients monitored by this same nurse the shift. The audit trail of the EMR revealed substandard and unsafe practices:

The nurse was monitoring another laboring patient at the same time as the plaintiff, against standards that required 1:1 patient monitoring during the administration of Pitocin for this patient.

The EMR time stamps revealed that the nurse made her entries on both patients long after her shift ended.

The fetal monitor alarm sounded twelve times during labor and was usually reset without any corresponding actions taken by the nurse. The alarm sounded when the signal was lost for one of the fetuses. The nurse was required to reposition the mother to reactivate the signal, however, this did not always occur. This resulted in hours passing without tracking Twin A’s heartbeat.

The entries for both patients, supposedly done at 15-minute intervals, were remarkably similar with little differentiation. Even more troubling, the  documentation implied that the nurse had been at two places at the same time while monitoring her patients.

All these findings called into question the integrity of the patient’s EMR.4

Many defense attorneys state “do not let documentation become a distraction in a medical malpractice case.” From a risk management and professional liability standpoint, the ability to rely on the medical record is of paramount importance in defending care. The medical record serves as the best witness to what occurred during patient care episodes. Often, the documentation and corresponding metadata will enable a defendant to prevail in a lawsuit. However, the documentation here became a significant distraction and helped to render the case indefensible.

Physicians and allied health providers have a duty to patients to document their care in a responsible manner with respect to standard of care. This entails accurate and timely documentation that is customized to the individual patient and situation, and that captures important details that might be forgotten. This practice is not only important from a patient safety and quality of care standpoint, but also important if care is called into question through any investigation or a lawsuit.

Bradford S. Dunkin is Assistant Vice President, Risk Management and Patient Safety, at CAP. Questions or comments related to this column should be directed to

¹Time-stamped EMR entries turn cases from defensible to candidates for settlement, July 21, 2014,… (accessed 05/02/23)

²Death at Birth: A Tragedy Caused by Overwork and Undertraining, Patrick Malone Associates, (website accessed 05/02/23)

³Order re: Motion To Compel Discovery, May 20, 2011 (accessed 05/02/23)

4Time-stamped EMR entries turn cases from defensible to candidates for settlement, July 21, 2014,… (accessed 05/02/23)