Be sure to keep medical records complete
Stressed Out Nurses Weekly, February 11, 2008
The medical record doesn't just convey the truth about the patient's care-it also illustrates the level of competence of the healthcare provider (you) and the truth about your commitment to safe, quality care. A complete medical record will:
- Tell the story of the patient's care
- Reflect the documentation of high-quality, non-negligent, competent care
- Serve as the best defense against allegations of negligence and fraud
Although nurses often view documentation as a dreaded task, healthcare professionals have a legal duty to maintain an accurate and complete medical record in sufficient detail.
Source: Stressed Out About Your First Year of Nursing, HCPro Inc., 2006. For more information on this book, click here.
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