Nursing CE Series: Nursing Documentation (Online Learning)
Reduce Your Risk of Liability
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Product Description:
Nursing Documentation: Reduce Your Risk of Liability
Earn 1 nursing contact hour!
The clinical documentation in a patient's record forms the basis for current and future care of that patient by all healthcare providers. Clinicians in your facility will rely on this record to make decisions regarding the patient's care. This record includes everything from the more "objective" type of documentation, such as the result of laboratory tests, to the more "subjective" type of documentation, such as what the patient/family said. In either case, the documentation should be as complete and detailed as possible. Documentation concurrent with treatment is the best way to accurately record care of the patient. Concurrent documentation is reliable, accurate, and most likely to actually reflect what occurred during the patient encounter. Patient care is more likely to be of a higher quality when it is based on accurate historical information about the patient.
Detailed documentation can also provide strong legal protection to the healthcare provider and the organization. In an action, a court will construe the absence of documentation as evidence against the defendant. Therefore, it is important that the patient's medical record contain detailed, complete, and accurate documentation in the event that the document is needed as evidence in a legal proceeding.
After completion of this course, you will be able to:
- Discuss the purpose of documentation
- Identify how the RN is held accountable for documentation
- Identify six categories of nursing negligence
- Identify why he or she should know Standards of Nursing and their state Nurse Practice Act
- Describe the critical elements of nursing documentation
- List eight charting errors to avoid
- List at least three risk-management pointers that ensure a well documented record
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