Nursing Documentation: Reduce Your Risk of Liability, Second Edition

Documentation may be the least favorite part of a nurse’s job—but it’s also one of the most important aspects. Incomplete or improper documentation poses a huge financial and compliance threat, including citations from state, federal, and Joint Commission surveyors. Plus, nurse managers can legally be held accountable for their nurses’ documentation.

Now packages of 25 handbooks are only $69!

Improve your staffs’ documentation with the handbook Nursing Documentation: Reduce Your Risk of Liability, Second Edition. Written specifically for staff nurses, this easy-to-read and affordable resource helps nurses understand the value of good documentation, and the consequences of not documenting accurately and in a timely fashion. The handbook’s case studies illustrate the legal threat nurses face from improper documentation, while the quick tips help them avoid common charting errors and improve their charting skills.

The handbook includes a short post-test and certificate of completion, allowing nurses to evaluate their documentation understanding. With this handbook as their guide, your staff will be motivated to a level of excellence that will be reflected in the medical record, resulting in improved overall quality of care at their facility.

Take a look at the table of contents:

1. What is clinical documentation?
2. The purpose of documentation
3. Your potential liability risks
   1. Threat to licensure
   2. Civil litigation
4. Case study 1: Documenting completely to avoid allegations of negligent care
5. Contemporary nursing standards
   1. Your state Nurse Practice Act
6. The consequences of an incomplete medical record
7. Case study 2: Failing to record pertinent health information
8. Eight common charting errors to avoid
9. Risk management recommendations
10. Top 20 tips for improving your documentation

Take a look at the companion book for nurse managers Managing Documentation Risk: A Guide for Nurse Managers, Second Edition provides nurse managers with strategies they can use to protect themselves, their staff, and their organization while continuing to offer the best quality of care. Completely updated with current regulations, this resource provides the most current requirements from The Joint Commission and CMS, as well as the latest information on electronic health records documentation and nursing diagnoses. This resource guides nurse leaders through assessing their organization’s current risks and designing a system for auditing staff documentation. It features an accompanying CD-ROM, including all the customizable strategic forms and audit tools included in the book ready for immediate use in your facility.