I’ve been a registered nurse (RN) for more than 30 years. I spent eight years as a travel nurse working in a variety of nursing roles, in every size and designation type of hospital from critical care access to large teaching university hospitals. I have seen the good, the bad, and yes, the ugly of healthcare. My experiences taught me many things, probably most importantly that I could be a voice against poor care.

In 2004 I made the choice to leave travel nursing to follow my heart and become a Certified Legal Nurse Consultant through LegalNurse.com’s CLNC® Certification Program. For the last 15 years I’ve provided review and analysis on medical malpractice, trauma, CMS fraud and criminal cases related to physical abuse.

I’m currently a quality analyst in information systems for a medium-size regional healthcare system. My role consists of analyzing nursing documentation built within in the electronic health record (EHR). I ensure it meets not only nursing, but also nursing informatics standards. I review daily nursing documentation for accuracy and routinely make suggestions for improvement in documentation policy and procedures. This consists of reviewing workflows in the record and going out on the units to see how those workflows match what actually occurs in the day-to-day operations. I assist in documentation system upgrades to make sure new data entries and workflows meet legal and regulatory standards and provide substantiated data collection for attestation to CMS and TJC.

I frequently provide education to the nursing staff on the intricacies of the legal aspects of correct documentation. I’m known to quiz frontline nurses on two subjects:

1. “Within defined limits (WDL)” criteria in the daily nursing assessment.
2. Whether the nurse would be able to thoroughly describe the care provided to the patient in question by reviewing her documentation if called into court five years later.

I believe this encourages nurses to critically think about what they are documenting, and not just click the easy “WDL” button.

I assist risk management in the review of records where there is a possibility of litigation. My knowledge and years of legal nurse consulting experience make me an excellent resource to simply review a record and give an opinion on the nursing care and documentation. My colleagues and executive administrators know they will get an honest review and not just what they want to hear.

Privately I consult with my own attorney-clients and provide the CLNC services I learned in the CLNC Certification Program. I offer one unique service in the early stages of jury selection. I’ve always been a people watcher and as an RN can pick up on subtle nuances in facial expression or body language. As such I can sit in a trial and observe potential jurors for signs that indicate a possible lack of objectivity in the case being presented. I then pass these observations along to the attorney-client who can then adjust questions and listen more closely to responses. My attorney-clients love this service.

Observing jurors is a favorite marketing tool. I’ve received calls from attorney-prospects who want to know exactly what I do in this regard. It has opened several doors that otherwise may not have been available to me. Not every attorney, no matter how seasoned, can observe people in the same way an RN can, so this service has become part of my unique selling position (USP).

I encourage all Certified Legal Nurse Consultants to think outside the box and come up with that one unique service that makes them shine. Remember, as the Institute says “We Are Nurses and We Can Do Anything!®”

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