For nurses and other healthcare providers, being ordered to appear for a deposition in a pressure injury case can be daunting. You may naturally worry that opposing counsel will expect you to recall a specific patient or defend every note you ever made.
We'll explore what to expect during these depositions and, more importantly, how strong documentation practices today can safeguard your patients, your facility, and your own professional protection in the future.
Depositions Aren't About Your Memory Alone
No one expects you to remember every detail about the patient bringing the lawsuit, especially if years have passed. Your testimony will be guided primarily by the patient's medical chart. And that chart doesn't just contain your notes. It's a compilation of entries from you, your colleagues, and various specialists.
The plaintiff's attorney often reviews that record to identify omissions, inconsistencies, or unclear documentation and uses them to argue that the defense did not provide proper care. If there's a gap in the record, they will almost certainly exploit it. As the old saying in litigation goes: "If it's not documented, it wasn't done."
You'll Testify to More Than Just Your Entries
In addition to discussing your notes, opposing counsel may ask you about your facility's standard practices, written policies, and procedures. Accordingly, you can expect to review these with the attorney to prepare. Strong, consistent documentation can be your best defense. When you chart thoroughly and consistently, you reduce the chance of being singled out as the designated witness, and it makes it easier for defense counsel to demonstrate that you provided appropriate care.
A Cautionary Case Study
In one case we handled, an older woman, living alone, fell down her stairs and was found more than eight hours later lying on her back. Upon arrival at the emergency department, an ED nurse documented intact skin. The admitting physician noted a bruise on her back. Interim nursing notes described Stage 1 redness on the sacrum.
Five days later, a wound care nurse identified a deep tissue injury (DTI), stating it had begun before admission. Subsequent notes described blisters and Stage 2 wounds as if they were new injuries, rather than existing wounds.
The lack of clear, consistent documentation made it difficult to establish the wound's origin and progression as one DTI. Lacking that clarity, we were unable to mount a strong defense, and we ultimately settled the case.
Documentation Best Practices to Protect Yourself and Your Facility
Strong documentation is your most effective shield in litigation. Here are key dos and don'ts drawn from years of defending these cases.
1. Maintain Consistency Across Shifts
When you document a wound, review prior notes to ensure consistency in staging and description. If there's no wound consult, check the previous nurse's entries before recording your assessment. Inconsistencies in staging can damage credibility and confuse the clinical picture.
2. Record Even When You Don't Change the Dressing
If you see a wound or dressing (such as Mepilex), note it, even if you aren't scheduled to change it that shift. This documentation shows awareness and vigilance.
When you change a dressing, include details about the wound bed and surrounding skin. While exact measurements aren't always necessary and often risk further inconsistencies, follow your hospital's policy, and measurements are critical if you are the first to assess the wound or the last nurse to describe the pressure injury prior to discharge.
Be positive where possible in your descriptions about the pressure injury:
- "Granulation tissue present"
- "No slough"
- "No signs of infection"
- "Stable" or "improving"
And never "backstage" (change the documented stage of a wound retroactively).
3. Act on and Document Changes
If a wound worsens, notify the RN manager, physician, or request a wound consult, and record your plan. Even if you decide the current dressing is adequate, explain your reasoning. Without this context, plaintiff's counsel may imply neglect.
4. Be Careful With the Term "Pressure Injury"
If another cause is possible, such as moisture-associated skin damage, venous or arterial ulcer, or diabetic ulcer, document that possibility. References to fragile skin can also help provide a fuller clinical picture.
5. Identify and Describe DTI Accurately
If you see signs of a DTI, don't avoid noting it. Describe its appearance, and if it evolves into an open wound, record that progression. Avoid creating ambiguity about whether it's a new injury.
6. Document Preventive Measures Every Shift
Consistency is critical. Turning and positioning (T&P) every two hours is considered standard care, despite mixed evidence on its effectiveness. Record it every shift, even if the patient can move independently, because other notes may later suggest limited mobility.
Include:
- Braden scores every shift
- Any specialty mattress or cushion placed during your shift
- Reminders to the patient to reposition
7. Don't Forget the TAR
Medication administration and treatment records (TAR) are part of the legal record. Make sure they are complete and accurate.
8. Record Refusals of Care
Patients may decline repositioning, wound care, or other interventions. Document these refusals; they may support a defense that the wound was unavoidable or worsened due to the patient's choices.
From Chart to Courtroom
From a defense perspective, your notes are often the only evidence we have to prove that care met the standard. Inconsistencies, omissions, and vague language give plaintiff's counsel ammunition. Detailed, consistent documentation allows us to:
- Demonstrate attentive, ongoing care
- Show that preventive measures were in place
- Establish an alternative cause or timeline for a wound's progression
- Counter claims that neglect caused the injury
In New York, as in other jurisdictions, the strength or weakness of the medical record often determines the outcome of pressure ulcer cases. Courts and juries give great weight to documentation made at the time of care.
If you are deposed, remember: opposing counsel will not test your memory alone, and they will focus on more than just your notes. It's about the story told by the entire chart. You can shape that story now by documenting with clarity, consistency, and completeness. In doing so, you protect not only your patients, but yourself and your facility from avoidable litigation risk.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
