Jackson v. Kelowna Hospital, (February 28, 2007), a recent decision of the British Columbia Court of Appeal underlines the importance of charting in accordance with hospital policy.

In this case, the patient arrived on the ward of a hospital at 21:45 hours and was assessed at that time by two nurses. The evidence with respect to what occurred after 21:45 was unclear. There was nothing in the hospital records indicating that any nursing staff thereafter attended to the patient. The hospital practice in these circumstances was to perform hourly rounds. However, the plaintiff’s girlfriend testified that no nurses attended in the plaintiff’s room after the initial assessment and before she left the hospital shortly before midnight. One nurse testified that she performed rounds at approximately midnight and that the plaintiff appeared to be sleeping and was breathing easily. She did not attempt to rouse him, check his sedation level, or check the PCA pump. Shortly thereafter, another nurse attended and found the plaintiff slumped over with noisy grunting respirations. A code blue was called and the patient was resuscitated.

After considering the evidence, the Court held that the nurses had breached the applicable standard of care, finding that they failed to follow PCA monitoring orders and failed to chart or document the plaintiff’s vital signs in accordance with hospital policy. The Court indicated that the charting did not inspire confidence. As a result, the nurses’ oral evidence that they monitored vital signs was held to be unconvincing.

This decision, released earlier this year, reminds us that charting is extremely important and often is key in either establishing or defending liability. In many cases, health care providers will have no or very limited recollection other than what is charted. Poor records can affect the credibility of health care providers and result in their evidence not being accepted by the Court.

You can access the full judgment at:

http://www.canlii.org/en/bc/bcca/doc/2007/2007bcca129/2007bcca129.html