Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Nursing DocumentationNursing Documentation
Author:
Meredith Scannell, RN, CNM, MSN, MPH
“If it wasn’t charted, it
wasn't done”
DocumentationDocumentation
• Nurses have a duty to maintain complete and
accurate recording of all the care thy provide.
•...
DocumentationDocumentation
• The medical record is a legal
document required by state laws
and regulations.
• Medical reco...
DocumentationDocumentation
• May be handwritten
• May be electronic
• Combination
DocumentationDocumentation
• Other uses for medical records:
-Education
- Research
- Substantiate reimbursement/insurance
...
DocumentationDocumentation
• Nurses are considered clinicians
• Role is not limited in the care of patients and in
past ye...
DocumentationDocumentation
• Risk exposure includes
• Assessment
• Communication a change in patient
condition
• Initial a...
DocumentationDocumentation
• Purposes
• Ensuring quality of care through
communication
• Legal evidence of the continuity ...
Safe DocumentationSafe Documentation
• Follow hospital/agency policy
• Failure to follow policy can result
inconsistencies...
““The palest ink is betterThe palest ink is better
than the strongestthan the strongest
memory”memory”
-Chinese proverb-Ch...
Safe DocumentationSafe Documentation
• Accuracy is critical
• Contemporaneously “chart as you go
• If ignored for too long...
Safe DocumentationSafe Documentation
• Hospital/agency policy are not laws.
• Used as standards that should have
been foll...
Safe DocumentationSafe Documentation
• Documentation based on Standards of Practice for
Registered Nurses when documenting...
Safe DocumentationSafe Documentation
• Patients name is on every page
• Everything must be legible
• Late entry
• Maintain...
Safe DocumentationSafe Documentation
• Chronology of events
• Date and time of entry
• Patient history
• Interventions
• O...
Safe DocumentationSafe Documentation
• Educational material given
• Understanding of educational material
• Referrals
• Co...
Documentation Don’tsDocumentation Don’ts
• Do not use the medical records as a battleDo not use the medical records as a b...
The EndThe End
Upcoming SlideShare
Loading in …5
×

Nursing Documentation

7,073 views

Published on

Nursing documentation is an essential aspect of nursing and can protect you in cases of litigation

Published in: Healthcare
  • Be the first to comment

Nursing Documentation

  1. 1. Nursing DocumentationNursing Documentation Author: Meredith Scannell, RN, CNM, MSN, MPH
  2. 2. “If it wasn’t charted, it wasn't done”
  3. 3. DocumentationDocumentation • Nurses have a duty to maintain complete and accurate recording of all the care thy provide. • Nurses working in specialty areas have greater risk for litigation exposure. • Complexities of care patients require more documentation
  4. 4. DocumentationDocumentation • The medical record is a legal document required by state laws and regulations. • Medical records are scrutinized by members of the litigation team. • Considered as important as testimony in courtroom. • Most important piece of evidence in a lawsuit alleging negligent practice.
  5. 5. DocumentationDocumentation • May be handwritten • May be electronic • Combination
  6. 6. DocumentationDocumentation • Other uses for medical records: -Education - Research - Substantiate reimbursement/insurance claims. • Can be used as legal evidence in litigation cases to establish if standard of care was met.
  7. 7. DocumentationDocumentation • Nurses are considered clinicians • Role is not limited in the care of patients and in past years there has been a paradigm shift. • Profession judgment • Highly skilled • Educated professions • Care delivered based on making clinical decisions based on assessments.
  8. 8. DocumentationDocumentation • Risk exposure includes • Assessment • Communication a change in patient condition • Initial and subsequent nursing diagnosis • Interpretation of diagnostic findings • Treatments • Changes in treatment plans • Medication adminstration and dosing
  9. 9. DocumentationDocumentation • Purposes • Ensuring quality of care through communication • Legal evidence of the continuity of care • Legal evidence of outcome of care • Assist in establish stands of practice • Provide a database for trending outcomes
  10. 10. Safe DocumentationSafe Documentation • Follow hospital/agency policy • Failure to follow policy can result inconsistencies and appear non-credible in a court of law. • Follow policies in how to make late entries.
  11. 11. ““The palest ink is betterThe palest ink is better than the strongestthan the strongest memory”memory” -Chinese proverb-Chinese proverb
  12. 12. Safe DocumentationSafe Documentation • Accuracy is critical • Contemporaneously “chart as you go • If ignored for too long, most likely forgotten • The higher the patient acuity the more frequent documentation. • Document conversations with other healthcare providers • Document nursing interventions before and after notifying another healthcare provider
  13. 13. Safe DocumentationSafe Documentation • Hospital/agency policy are not laws. • Used as standards that should have been followed. • Used as standards that were met.
  14. 14. Safe DocumentationSafe Documentation • Documentation based on Standards of Practice for Registered Nurses when documenting information. • Defined by state and federal laws. • Nurses Practice Acts: specific state requirements that nurses shall be responsible and accountable • Specific Standards from Association of Women’s Health, Obstetric and Neonatal Nurses, The National Association of Neonatal Nurses. • Federal and state organizational standards; The Joint Commission, Centers for Disease Control
  15. 15. Safe DocumentationSafe Documentation • Patients name is on every page • Everything must be legible • Late entry • Maintain objectivity and not opinions
  16. 16. Safe DocumentationSafe Documentation • Chronology of events • Date and time of entry • Patient history • Interventions • Observations • Outcomes • Patient and family responses • You signature and credentials
  17. 17. Safe DocumentationSafe Documentation • Educational material given • Understanding of educational material • Referrals • Consents • Discharge plan • Follow up • Telephone calls (providers and family)
  18. 18. Documentation Don’tsDocumentation Don’ts • Do not use the medical records as a battleDo not use the medical records as a battle groundground • Do not blame and individual or departmentDo not blame and individual or department • Limit finger pointing and focus on problemLimit finger pointing and focus on problem solvingsolving • DoDo not chart opinionschart opinions
  19. 19. The EndThe End

×