Accurate documentation can help your facility avoid litigation
Staff Development Weekly: Insight on Evidence-Based Practice in Education, August 18, 2006
Want to receive articles like this one in your inbox? Subscribe to Staff Development Weekly: Insight on Evidence-Based Practice in Education!
Now more than ever before, the medical record is used for many purposes and by many people who focus on specific areas of the clinical record or particular words/phrases to determine cause and effect. It's crucial to understand that documentation is the key to avoiding allegations of malpractice, substandard or poor nursing care, and denial of reimbursement.
The nurse should ask himself or herself the following questions:
- What is the purpose of this entry?
- Did I use a process that ensures clear, complete, and concise documentation?
- Did I follow my organization's policies and procedures for documentation?
- When I audit my nursing documentation have I communicated the information clearly to other team members or anyone who reads this clinical record?
Want to receive articles like this one in your inbox? Subscribe to Staff Development Weekly: Insight on Evidence-Based Practice in Education!
Related Products
-
Strategies for Nurse Managers
Strategies for Nurse Managers is a 12-page monthly how-to newsletter that was created exclusively to help you save time...
-
Nurse Leader Weekly
Our informative free e-mail newsletter for nursing professionals delivers helpful tips and advice each week!
-
Staff Development Weekly: Insight on Evidence-Based Practice in Education
This e-mail newsletter reports on innovative training methods and mandatory training requirements. You'll also find tips on...
-
From Hostility to Collegiality:
Nurse retention, nurse satisfaction, patient safety, and quality improvement are all compromised when hostility permeates...
-
Nurse Accountability: Six Steps to Create a Culture of Commitment
This 90-minute webcast introduces six cutting-edge concepts to help you get people to make and keep commitments. Speaker...
Most Popular
- Articles
-
- HIPAA Q&A: Answering service messages
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Q&A: Coding for dry skin due to cold weather
- Q/A: Volume requirement for reporting hydration services
- Are your workforce members texting PHI?
- Topic: CMS, OESS post new security compliance review information, checklist
- What does case-mix index mean to you?
- Privacy, security concerns high in HIEs
- QA:Coding multiple initial infusions
- OB services: Coding inside and outside of the package
- E-mailed
-
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Q/A: Volume requirement for reporting hydration services
- HIPAA Q&A: Level of encryption needed for email
- HIPAA Q&A: Answering service messages
- HIPAA Q&A: TPO disclosures to a business associate
- Are your workforce members texting PHI?
- Q&A: Coding for dry skin due to cold weather
- Hospitalist-surgeon comanagement has no effect on outcomes
- Don't let these sentinel events trigger falsely
- Correctly bill ancillary bedside procedures in addition to the room rate
- Searched