Automated clinical pathways in the patient record legal implications.

Abstract

Nurses have long been taught the need for precise documentation of patient care. Yet, as demands on nurses' time increases, maintaining an accurate and informative patient record becomes more difficult. The use of an automated clinical pathway that contains both the plan of care and a record of the care, while increasing communication between the care providers, is a promising solution to the problem. In this article, the process of moving a clinical pathway from paper to a computerized format is discussed. Legal issues related to its status as a permanent part of the patient record are considered. The legal implications of the pathway as a standard of care are also examined. As clinical pathways and computers merge, effective automated plans of care that also can serve as a documentation tool will benefit both the caregiver and the patient, while decreasing the risk of liability.