Documentation for Nurses

A well-documented patient medical record is one of the best ways to stay out of the courtroom. This course presents tips on improving documentation, essential components for meeting professional and regulatory requirements, and charting steps to avoid litigation. OBJECTIVES: 1) Examine the impact of nursing documentation on patient care, nursing career, and reimbursement. 2) Examine sample forms used in documenting patient care. 3) Identify professional and regulatory requirements for documenting patient care. 4) Discuss the trend toward computerized documentation. 5) Apply the nursing process to improve sound documentation. 6) Discuss documentation methods and the advantages/disadvantages of each one. 7) Describe various charting strategies to improve documentation. 8) Identify steps to take when preparing for the defense of a malpractice lawsuit. 9) Specify documentation disasters that may lead to a potential lawsuit. 10) Identify proper documentation of an incident report. 11) Discuss charting practices to decrease liability risk.