The Most Common Evidence Nurses Forget to Save, Putting Their License at Risk

Whether you’re working shifts at a clinic or hospital, meeting regular patients at a doctor’s office, or moving from place to place as a travel nurse, you’ve probably seen enough on the job to know how easily things can go sideways: someone’s claiming a patient got the wrong meds, or that their vital signs were recorded incorrectly, or that equipment’s gone missing, or any one of the thousands of things that can be misunderstood, miscommunicated, switched, swapped, dropped, forgotten, or confused in a busy healthcare setting.

In moments of panic and finger-pointing, nurses need to have the presence of mind to both address the crisis at hand and look out for their own self-preservation. This means saving any evidence that can show that, whatever the issue, they followed instructions and adhered to standard protocols and professional best practices. Without evidence, a nurse under investigation by their state’s professional licensing board might not be able to make a convincing case that the incident was not their fault.

Here’s a list of the most common kinds of evidence nurses forget to save, putting their licenses and livelihoods at risk. If you’re a nurse under investigation by your licensing board, the Professional License Defense Team at the LLF National Law Firm can help. Call us at 888-535-3686 or send us a message online.

Save This Evidence!

The most common types of evidence nurses under investigation and at risk of losing their nursing license realize they should have saved are:

• Shift notes. These are the notes you jot down to stay on track, ticking off each task as you complete it. Never throw them away at the end of a shift. These can show the times you administered medications and the dosage, when you clocked in and out, your observations of a patient’s condition, and anything else you’re clocking on your shift.
• Medication Administration Records (MARs). Screenshot completed MARs showing each patient’s dosing instructions and when (or whether) they were administered. Save the screenshot or download the record onto a staff computer. (Do NOT save this information on a personal device — you don’t want to violate HIPAA rules.)
• Communications. Unless it’s about a potluck or pitching in for Janeen’s baby shower, save every email, text, or other message you receive pertaining to patient care, office administration, or practices (shift changes, etc.) from supervisors, colleagues, and physicians.
• Timesheets and logs. If you clock out for a break, leave early, or come in a little late, save that information. You can keep your own personal record in your shift notes (above), but electronic timestamps of your comings and goings are even better.

It almost goes without saying that you’ll also want to always keep the list of your credentials, including trainings, continuing education courses, and performance reviews, updated and filed neatly filed away where you can easily find it for board investigators.

Protect Your License, Protect Your Livelihood

Protecting your license starts before an incident even occurs. If it proves you did what you were supposed to do, save it. Every shift, every day. With or without exculpating evidence, navigating a licensing board investigation isn’t easy. You need to understand the rules and the process, and you need to present your evidence in the right form and in the appropriate context. The LLF National Law Firm’s Professional License Defense Team helps nurses across the U.S. manage their investigations. If you’re facing one, too, send us a message online and tell us about your case, or call us at 888-535-3686.