Practice defensive documentation
Stressed Out Nurses Weekly, November 12, 2007
Keep in mind that immediately following an adverse event, documentation may be reviewed by the quality and risk-management departments, the physician, the patient/family, and others. Also remember that what is written at the time of the event will have to stand on its own merit for five years. It may take that long for it to go through the legal process.
Read your documentation after it is written and ask yourself these questions:
- Is my documentation factual, objective, complete, and as accurate (FOCA) as possible?
- Will it make sense to any reader?
- Do I have the accurate date, time, and sequence of events?
- Will I remember the intent of my documentation if called into question?
Source: Stressed Out About Your First Year of Nursing, HCPro Inc., 2006. For more information on our series of Stressed Out books, visit www.stressedoutnurses.com
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