Risk Management Nursing Documentation Nur 492

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Risk Management Nursing Documentation Oscar Chavez NUR 492 May 4, 2012 Susan Dean, RN, MSN, FNP Risk Management Nursing Documentation The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk…show more content…
Usually, the persons or committees they work with have already identified deficiencies; however they might have not defined or identified a specific situation. Intermittently, after discussion of some deficiencies, it is concluded that interventions other than training are more appropriate. For example, a systems problem may be identified, such as a medical record form that is not well designed or none conducive to the documentation of appropriate and complete data. Issues may be more appropriately addressed through supervision and management, such as completion of vital signs and intake or output documentation at the end of each shift. Risk management along with other staff members work together to specifically identify and delineate the areas of deficiency chosen for improvement. The criteria for proper documentation are determined through reference to accepted nursing standards or principles of risk reduction in medical record documentation. Baseline data from medical record audits should be obtained before building an education program. This data will be compared to data collected after the education program on documentation, to establish its effectiveness. Often the baseline data will already exist. The medical record reviewer or nursing committee who identified the deficiencies will have months of data collected, quantifying the extent of the deficiency. Once the measurement

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