Negligence, malpractice, and legal documentation

Legal liability items reward precision. The NLE asks you to label a scenario as negligence or malpractice, identify which element of liability is missing, and pick the charting behavior that stands up in court.

Negligence versus malpractice

Negligence is the failure to do what a reasonably prudent person would do in the same situation, or doing what a prudent person would not do. Anyone can commit negligence. Malpractice is professional negligence: a licensed professional's failure to meet the standard of care of the profession, causing harm while performing professional duties. All malpractice is negligence, but not all negligence is malpractice.

Feature	Negligence	Malpractice
Who commits it	Any person	A professional acting in a professional capacity
Standard used	Reasonably prudent person	Standard of care of the profession
Example	A visitor leaves a spill that causes a fall	A nurse infuses the wrong intravenous drug and injures the client

Common nursing malpractice sources: medication errors, burns from heat applications, falls after failure to raise side rails, foreign objects left after procedures, failure to monitor and report changes, and failure to communicate with the physician.

The four Ds of professional negligence

For a malpractice claim to succeed, the plaintiff must prove all four elements:

1. Duty: a nurse-client relationship existed, creating an obligation of care
2. Dereliction (breach of duty): the nurse fell below the standard of care
3. Direct causation: the breach directly caused the injury (proximate cause)
4. Damages: actual harm or injury resulted

Remove any one element and liability fails. A nurse who breaches the standard but causes no injury is not liable for malpractice, though administrative sanctions remain possible. Related doctrines: res ipsa loquitur ("the thing speaks for itself") applies when the injury obviously would not occur without negligence, such as a clamp left inside the abdomen; respondeat superior ("let the master answer") makes the employer share liability for employees' acts within the scope of employment, but it never erases the nurse's personal accountability.

Documentation as legal evidence

The chart is a legal document and often the only witness years after an event. Courts follow the rule: care not documented is presumed not done. Charting principles:

• Chart facts, observations, and exact client quotes, not opinions or labels
• Chart in real time or as soon as possible; note late entries as "late entry" with the actual times
• Never chart in advance and never chart for another person
• Correct errors with a single line through the entry, the word "error" or per agency policy, then initial; never erase, blot out, or use correction fluid
• Leave no blank lines; draw a line through unused space
• Use only agency-approved abbreviations; sign every entry with name and title
• Document refusals, safety measures taken, physician notifications with exact time and response

Incident reports

An incident (unusual occurrence) report is an internal quality improvement and risk management tool completed by the person who witnessed or discovered the event. Rules the exam tests:

• Complete it for any unusual event: falls, medication errors, needlesticks, lost items, injuries to visitors or staff
• Describe objectively what was seen and done; no blame, no conclusions
• Do NOT mention the incident report in the client's chart, and do not attach it to the chart; chart only the factual event and care given
• Notify the physician and document assessments and interventions in the record
• Filing an incident report is not an admission of guilt; it exists to analyze and prevent recurrence

Key points

• Negligence is failure of ordinary prudence by anyone; malpractice is professional negligence measured against professional standards.
• Memorize the four Ds: duty, dereliction, direct causation, damages; all four must be proven.
• Res ipsa loquitur shifts the burden when injury speaks for itself; respondeat superior adds employer liability without excusing the nurse.
• Chart facts only, in sequence, with corrections made by a single line, never obliteration.
• Incident reports stay out of the chart; the chart records the event and care, the report goes to risk management.
• For exam stems, first check whether harm occurred; without damages there is no successful malpractice suit.