Web site spotlight: Reasons to document
Staff Development Weekly: Insight on Evidence-Based Practice in Education, March 6, 2008
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Nurses must assume responsibility for ensuring complete and accurate documentation. In today's culture of accountability, your title and scope of responsibilities will bring under scrutiny your commitment to safe and quality patient care, so you need to accept the responsibility whether it is part of your job description or not.
The major reasons for documenting nursing care include:
- Documentation of the plan of nursing care
- Evaluation of the effectiveness of the nursing care provided
- Facilitation of communication between the patient/family and other providers
Editor's note: This excerpt was adapted from HCPro's book "Managing Documentation Risk: Tools for Nurse Managers, Second Edition," by Patricia A. Duclos-Miller, MS, RN, CNA, BC. For more information on this resource (and many others!), click here to see inside our books at www.StrategiesForNurseManagers.com!
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