Overview Of Nursing Documentation

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Documentation is a very important task that all nurses must do when working in the healthcare field. Accurate documentation not only assures high quality patient care but is our best defense in a malpractice lawsuit. Avoiding malpractice by proper and complete documentation is about more than just avoiding a lawsuit making it to court; it is about avoiding the litigation process entirely. We need to remember that documenting has to be legible, complete, and thoughtful to prevent risks for litigation. A patient's chart is a medical and legal document.
When documenting, nurses must keep in mind that the information has to be complete, correct, and timely. Incomplete, misleading or missing documentation create problems when presented as evidence
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just to mention a few. Lawyers use these policies and procedures (P&P’s) against nurses to judge their actions. Failure to follow P&P’s is among the most frequent allegations against nurses in lawsuits (Professional nursing, 2016). One of the cardinal principles of legally defensible documentation is strict adherence to organizational policy and procedure (Professional nursing, 2016). It is also important to note that documentation policies differ from unit to unit even within the same facility. Familiarize yourself with the standards of the unit you are assigned…show more content…
When possible, you should avoid documenting by exception (a quick method commonly used to document normal findings that includes defined normals) i.e. “a care activity is assumed done unless charted otherwise” (Proactive prevention, 2016), because this can be considered as careless documentation, leading to unclear communication. We need to remember that documenting has to be complete and thoughtful to prevent risks for litigation. Again, a patient's chart is a medical and legal document.
My example of correct documentation that I am going to use today is based on my recent experience in the CVOU. I took care of one of my nurse's patients through the entire cardiac procedure. All my interventions were important, so I documented them as soon as they were done. During post procedure, I had to assess the patient's femoral incision site for bleeding and swelling or hardening, legs for color and edema, and pedal and popliteal pulses q15 min x4 and q30 min x2. Although, I was taking care of another patient at the same time, I kept in the back of my head the need to assess my primary patient during each time frame, and documented my findings right away, which takes only a minute or two so there was no delay documentation, which may have led to
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