Uploaded by PalomaHomeHealth on Jan 2, 2011 Avoiding malpractice is more than avoiding a lawsuit, it is avoiding the litigation process altogether. Proper documentation is arguably the most important element in avoiding malpractice and litigation for nurses. There are many reasons why nurses spend much of their time charting. However, when it comes to malpractice and the litigation process, documentation may be the only evidence a nurse has to defend his or her position. By the time a lawsuit is filed, chances are the nurses will not remember the particular patient involved, especially if they only cared for the patient for one or two shifts. Even if the nurses do remember the patient, it is their documentation that will be reviewed, presented and relied on, not their memory. All nurses have been taught, “If it’s not written, it’s not done!” But, what exactly does that mean? Whether you are a student nurse or have been in nursing for thirty years, this question may be difficult to answer. Over the years, documentation has changed a great deal. But, the rationale behind why documentation is important remains the same. Whether you are documenting with a narrative style, using flow sheets or charting by exception, the purpose of documentation is to memorialize what occurred while you took care of your patient and to capture relevant information about the patient’s condition and medical history. The more accurately your documentation depicts what actually happened during the …
Video Rating: 0 / 5
