Help your staff improve documentation skills
Staff Development Weekly: Insight on Evidence-Based Practice in Education, September 29, 2006
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In addition to physicians, nurses' (and therapists') documentation affects patient safety, reimbursement, risk management, and more, so it's important that everyone work toward thorough and accurate documentation. The following pointers are useful ideas to help your nursing staff improve their documentation:
-At the point of hire is a good time to explain the expectations for documentation and the legal ramifications of inadequate documentation. In some facilities, new nurses go through an orientation and are buddied up with another RN. During orientation, trainers go through nurses' notes, assessment, daily care records, and medication records.
Editor's note: The above excerpt is from the online course, "Nursing CE Series: Nursing Documentation - Reduce Your Risk of Liability." For more information on this and other courses in our library, go to http://www.hcprofessor.com/.
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