Guilty Or Innocent Protecting Your License Through Proper Nursing Documentation

With all the training and education nurses receive, there is little true explanation about the importance of documentation. Even in today's litigious culture and the backlash of services no longer reimbursable -- it is crucial we as nurses understand the rationale for our documentation practices. By creating specific systems to ensure license protection, we in turn provide more effective hand- off communication. Every nurse knows it's the law and that you don't want to lose your license, but do we really know why the methods of documentation are so vital to our livelihood? Has the electronic medical record made this approach additionally arduous? Do the questions on the EMR provide an accurate picture of the actual care provided? Often times, these reports are not clear or complete. Through fictional and non-fictional stories, Rosale Lobo reveals proper nursing documentation techniques providing clarity and important best practice concepts that can be applied immediately. Extraneous situations will arise in nursing, making it imperative to develop intentional methods of documentation. By putting together an effective system you will decrease your chances of being sued. For the future of nursing documentation, the EMR is not the answer, a personal system of accountability is.

You can be an excellent nurse in the clinical setting and still fail to prove that you are an excellent nurse if your documentation is inadequate. Having worked in a variety of inpatient and outpatient settings, I understand the obstacles nurses face. There's just not time, nor do nurses have the mental energy to meticulously document every little thing on top of the rest of their to-do list. That's part of why I became passionate about documentation education. It doesn't have to be an overwhelming, endless challenge to chart exhaustively in hopes that you enter enough data into the chart to defend yourself one day. Rather, leveraging the most critical data, knowing how to format notes and exactly what to say, and when to spend five minutes dumping information into the chart can be learned skills that make documentation faster, easier, and less stressful, while doing a better job of defending your actions. The Importance of Documentation & Overcoming Obstacles Purpose(s) of Documentation Defensive Charting Obstacles Impacting Quality of Medical Record Overcoming Obstacles Legal Responsibilities of the Nurse Duties of the Nurse Nurse Practice Acts Duties of the Hospital Hospital Policy vs. State Board of Nursing Regulations Reasonable Prudence Failure to Fulfill (Document) Responsibilities Fulfilling Responsibilities vs. Documenting Responsibilities What if Responsibilities Aren't Fulfilled? Mistakes Happen Professional Liability Insurance Malpractice Medical Negligence Acting with Malice Fraud What Happens When a Nurse is Charged with Malpractice? What to Do if You Receive Notification of a Claim Common Charting Mistakes & How to Avoid Them The Most Common Errors Charting By Exception & Charting to Capture Minimal Data "But I've Always Charted This Way, and Nothing Bad Has Happened Yet..." What You Should Be Charting How and What to Chart Quick Glance Charting Checklists What is a Timely Manner? Documenting Assessments Sample Focused Assessment Criteria Sharing the Responsibility Modifying Electronic Data Abbreviations Standing Orders Early Warning Systems Scores & Scales Informed Consent Special Circumstances Paper Charting Writing an Incident Report Patient Leaving AMA Patient Threatening to Sue You Identifying Patient Belongings Another Member of the Team is Not Documenting Correctly Restraints Defective Equipment Suspected Abuse Patient Requesting to View Their EMR on Hospital Computer Narrative Notes When & How to Write Notes One Note or Several Notes? Daily Narrative Notes Examples of Common Notes Written As-Needed How to Title Narrative Notes How to Format Notes Using Patient Names in Notes Length of Notes Create a Template Tips for Less Stress When Charting BONUS: How I Chart on a "Typical" Shift ABOUT THE AUTHOR: I'm Andrea, RN-MSN. Perfecting my own documentation and working to find concrete guidelines to share with my fellow nurses has become my passion. As I gained more knowledge and researched the dusty, forgotten corners of the internet for obscure evidence-based practice and case studies, becoming a subject matter expert on nursing documentation lit a spark because sharing this information helps empower nurses to understand exactly what should appear in their patient charts, where, when it should entered, and how it should be phrased.

Focusing on the legal implications in the US, this book is designed to meet the needs of professional and student nurses in determining how they should be recording their practice.

Fully updated to mirror the test plan for the latest CCRN®-Adult certification exam, Dennison’s widely acclaimed PASS CCRN®! is known for its targeted yet comprehensive content review, innovative learning strategies, and meticulous accuracy. This new fifth edition addresses each section of the most current CCRN® exam in detail, with review content presented in a quick-reference outline format and supported by a wealth of illustrations, tables, and algorithms. Learning activities for each chapter, as well as more than 1,000 review questions on the companion Evolve website, offer valuable practice and test-taking experience to prepare you for success on the CCRN®-Adult exam. More than 1,000 multiple-choice review questions on the companion Evolve website offer convenient electronic access and can be answered in Study Mode or Exam Mode. Outline-style review helps ensure that you have mastered essential content for the CCRN®-Adult exam. Engaging, chapter-ending learning activities provide fun and stimulating ways for you to learn critical concepts. Content is supported by a wealth of tables, illustrations, and completely new algorithms to help clarify complex concepts. NEW! Completely updated content follows the latest CCRN®-Adult exam blueprint to ensure that you have the most current information for exam preparation. NEW! Integumentary and Musculoskeletal Systems chapter reflects the latest CCRN® exam test plan organization. NEW! Thorough revisions to the Professional Caring and Ethical Practice and Multisystem chapters match the latest CCRN®-Adult exam.

NEW! Over 50 new and revised illustrations reflect the latest perioperative procedures, techniques, and equipment. Updated content ensures you have the latest information on key topics, including: Computerized documentation "Never Events" and reimbursement Credentialing and certification Bioterrorism and prion contamination Surgical hand hygiene, gowning, and gloving Wound healing and hemostasis Surgical instrumentation NEW! References throughout the text highlight the importance of evidence-based practice. Expanded coverage in the Administration of Perioperative Patient Care Services chapter features managerial approaches to TeamSTEPPS and SCIP, as well as magnet status. Updated physical plant information offers the latest 2011 updates concerning air-flow and room size according to AAMI standards.