Medical errors. Lost reimbursement. Unfavorable survey outcomes. Damaging lawsuits.
Improper documentation in a resident’s clinical record can have dire consequences for your skilled nursing facility. The clinical record drives quality of care, supports the MDS, and helps to defend your facility during surveys and litigation. That’s why it’s essential that all your clinical staff have a solid understanding of proper documentation processes and procedures.
Introducing Documentation Guidelines for the Clinical Record
Developed exclusively for nurses and clinical staff in the long-term care setting, these handbooks provide the who, what, where, why and when of the clinical record. Sold in packs of 20 for only $99, distribute this vital reference tool to every member of your nursing staff—it’s the most economical way to protect your facility and residents from documentation errors.
At 28 pages each, the Documentation Guidelines for the Clinical Record handbooks are concise enough to be used a daily reference, yet thorough enough to provide the information a nurse needs for correct documentation. In addition, each handbook includes a form to be signed by the recipient that documents receipt and understanding of the contents.
Take a look! Look to the left to download a sample copy of the handbook to see for yourself the crucial and useful information it contains.
All the information you need to solve your documentation problems
In each copy of the Documentation Guidelines for the Clinical Record, you’ll find expert information to help your nurses maintain continuity of care from one caregiver to the next and educate them about effective communication. The handbook focuses on the essential pieces of the clinical record, including how to document properly and correcting errors when they occur, timing and dating entries, inserting late entries, and similar dilemmas that challenge nurses on a daily basis.
Take a look at our table of contents:
- The clinical record
- The purpose of documentation
- Date and time entries in the chart
- Signatures
- Initials
- Legibility
- Chronology of entries
- Basic documentation rules
- Omissions, additions, clarifications, and corrections in documentation
Save money when you purchase multiple copies! Ask your customer service representative about money-saving
discounts and bulk orders. Call toll free 800-650-6787 or e-mail
customerservice@hcpro.com.
