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Documentation You’ve got a lot to lose American Nurse ~ The nursing student left one line between her charting and the night nurse’s charting Above the nursing student’s charting the dayshift charge nurse inserted “IV infiltrated and discontinued” noted the time she wrote her note end of shift and signed it
Nursing Documentation How to Avoid the Most Common ~ When it comes to nursing documentation knowing how to accurately document a patient can literally mean life or death Some of the most common medical documentation errors can also be the most disastrous Plus improper documentation can open up an employer to liability and malpractice lawsuits
ANA’s Principles for Nursing Documentation ~ Nursing documentation such as patient care documents assessments of processes and outcome measures across organizational settings serve to monitor performance of health care practitioners’ and the health care facility’s compliance with standards governing the profession and
Importance of Documentation in Nursing The Dos and Don ~ Importance of Documentation in Nursing The Do’s and Don’ts December 20 2012 Nursing Articles 47076 Views If you are a registered nurse who dreads documenting the care you provide to patients—you are not alone Many nurses dread documentation because it takes them away from patient care but proper documentation can help nurses avoid
Nurse documentation contributes to lawsuit dismissal ~ Our legal information columnist Nancy J Brent MS JD RN received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation consultation and education for healthcare professionals school of nursing faculty and healthcare delivery facilities
The legalities of nursing documentation Nursing2019 ~ Therefore documentation is the creation of a legal document reflecting optimal patient care given in accordance with appropriate standards of care the scribe The nurse is also documenting for her own purposes Documentation thats complete and accurate can also serve as a memory refresher when details are unclear or forgotten
Lippincott NursingCenter Nursing Pocket Card Nursing ~ Nursing Documentation Remember the old saying “if it wasn’t documented it wasn’t done” The purpose of the medical record is to provide a clear and accurate picture of the patient while under the care of the healthcare team Campos 2009
Documentation by the Nurse Texas Health and Human ~ Proper Documentation Example 1 032114 0800 Mrs GH alert awake and oriented to person and situation but is confused as to time and place She is able to state her name and that she is in the nursing home but states that it is afternoon and that it is 1990
Professional Nursing Documentation ~ 4 Identify documentation practices that create legal and professional risks 5 Identify characteristics of nursing documentation that support a legal defense of nursing actions 6 Identify employment and licensure implications of nursing documentation 7 Explain nursing documentation requirements for specific aspects of care including critical
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