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Documentation: tips to reduce liability

Staff Development Weekly: Insight on Evidence-Based Practice in Education, December 13, 2007

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The documentation in a patient's record forms the basis for current and future care of that patient by all healthcare providers. Clinicians in your facility will rely on this record to make decisions regarding the patient's care. This record includes everything from the more "objective" type of documentation, such as the result of laboratory tests, to the more "subjective" type of documentation, such as what the patient/family said. In either case, the documentation should be as complete and detailed as possible. Here are some concrete suggestions to improve documentation:

• Write legibly. Regulatory bodies now cite facilities if the medical record cannot be read. The reason is simple: Any illegible entry could be misconstrued and lead to an adverse medical event. Patient safety is first and foremost.
• Date and time all entries. Doing so accurately documents all nursing actions and patient responses.
• Every entry must be accounted for. Sign your name and credentials for every entry, even if it is one line.

Editor's note: The above excerpt is from the online course "Nursing Documentation: Reduce Your Risk of Liability." For more information on this and other courses, visit the eLearning Library at StrategiesForNurseManagers.com!

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