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July 7, 2011 |
Dear
Colleague,
Inaccurate or incomplete documentation can lead to serious legal trouble. I’d like to share the following “red flags” to avoid in your documentation. These are from Stay Out Of Court With Proper Documentation in the April issue of Nursing2011.
Avoid the following in your documentation:
- sloppy, incomplete, inconsistent, or illegible notes; or notes that have gaps
- notes that aren’t timed or dated or that appear out of sequence
- notes that indicate delays or failures in initiating treatment orders
- notes that show the care provided was substandard or inappropriate
- notes that show care given wasn’t supported by a prescription or order
- unexplained late entries
- erased or obliterated entries
- lack of documentation of patient education or discharge instructions
- entries made with different ink or pen (if handwritten)
- the statement “Completed an Event Report”
Read more about legal issues by exploring the articles in More Resources. You can also browse recent issues of JONA's Healthcare Law, Ethics, and Regulation. Our next issue will focus on hypertension and will include a new selection of CEs and articles. Be sure to check it out!
Lisa Bonsall, MSN, RN, CRNP
Clinical Editor
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We are very excited to be announcing our new Skin Care Network! We’ve pulled together, organized, and added special features to all of the dermatology and skin care related content from our journals! If you are a nurse or nurse practitioner practicing in dermatology, interested in dermatology, or if your patients ever ask you questions about their skin, you must come take a look around! Here’s the link: NursingCenter’s Skin Care Network. You can even ‘like’ the Skin Care Network on Facebook and follow the Skin Care Network on twitter too!
In my latest post on NursingCenter's In the Round, I share a great article from the Journal of Perinatal and Neonatal Nursing. It really is a must-read for all nurses, so if you haven’t already seen it, I encourage you to do so today! Here’s the link to the blog post: Are you a nurse leader? Yes!
Rheumatoid arthritis is characterized by persistent inflammation of the synovium and extra-articular sites. Learn more about this disabling autoimmune disease in Recognizing and Managing Rheumatoid Arthritis.
Nursing2011 Share:
(2 contact hours)
Why is the ED dangerous? For explanations from the authors as well as recommended prevention strategies, take some time to read ED Violence: Occupational hazard?
Nursing Management Share:
(1.6 contact hours)
Find ways to create transformation in patient care through reflection in practice, clinical supervision, leadership, education, and evidence-based practice. Don’t miss Reflective Practice for Personal and Professional Transformation.
Journal of Christian Nursing Share:
(3 contact hours)
Review our Recommended CE list on intentional self-injury, menopause and the hormone controversy, learning with technology...
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In Fluid and Electrolyte Series: Balancing act Na+ Sodium K+ Potassium, review the normal functions of two key electrolytes, plus refresh your knowledge of nursing assessment and intervention when imbalances occur.
Nursing2011 Share:
As nurses, we play an important role in screening, treating, and documenting domestic violence. Don’t miss these 10 Tips for Documenting Domestic Violence.
Nursing2011 Critical Care Share:
Communication and collaboration improve patient outcomes and job satisfaction among nurses. Read about An Educational Program to Promote Positive Communication and Collaboration Between Nurses and Medical Staff.
Journal for Nurses in Staff Development Share:
Browse our Recommended Readings on education and income, bad day or horizontal violence, a tale of two medication errors, and more.
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Read the articles in the latest Featured Journal online only on NursingCenter. The Featured Journal gives you the opportunity to get acquainted with the kind of coverage and clinical information it has to offer. Get to know our journals. The current Featured Journal is...
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The FDA has approved modified recommendations for more conservative dosing of erythropoiesis-stimulating agents (ESAs) in patients with chronic kidney disease (CKD). The new recommendations are based on clinical trials showing that using ESAs to target a hemoglobin level of greater than 11 g/dL in patients with CKD provides no additional benefit other than lower target levels and increases the risk of serious adverse cardiovascular events, such as heart attack or stroke.
See more drug news.
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NEW! From the American Journal of Nursing
Sign up now for the new AJN eNews, a monthly newsletter delivered to your inbox, containing the latest clinical, nursing, and health topics. AJN's standards for accuracy and excellence, which have made us "the leading voice of nursing" for over 100 years, continue in this medium, as a trusted source for news on clinical practice, health care policy, professional issues and the "business of nursing, and drug and product alerts. |
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