Best Practices in Nursing Documentation: Writing Effective and Legal Proof Notes

Best Practices in Nursing Documentation: Writing Effective and Legal Proof Notes

Understand the compliance challenges in documentation and make medical records as accurate as possible. Long gone are the days that nurses and other health care providers hand-wrote cryptic notes on essay paper-like chart pages that rarely were ever looked at again. Long gone, also, are the days that physicians would only look at labs, reports and other physicians’ notes, expecting the nurse to call to the physician’s attention anything important about the patient so they didn’t have to read nurses’ notes. The information documented about a patient will live on and be seen by a multitude of individuals. It has become even more important to document accurately, succinctly, intelligibly and professionally. This topic will place documentation of patient care in its rightful place, summarize its multiple purposes, describe appropriate documentation, and highlight pitfalls of bad documentation and its consequences. This topic will introduce you to how the legal system uses documentation, techniques to avoid problems and what you might be required to do at some time in the future with respect to your documentation or lack thereof. The standards that are applied to documentation will also be discussed briefly. Last, but not least, you will be able to ask questions and will learn from unfortunate examples of others’ documentation and the consequences of those failures.