Nurse Documentation: Not Done or Worse, Done the Wrong Way—Part I

Marilyn Frank-Stromborg

Anjeanette Christensen

David Elmhurst Do

documentation, nursing documentation

Purpose/Objectives: To focus on nursing documentation and expanding technologies (e.g., facsimile, telephone, e-mail, computer charting) that offer different ways to record, deliver, and receive patient records and avoid nursing liability for inadequate or inaccurate documentation.

Data Sources: Nursing, non-nursing healthcare, legal journals, case law, and related Internet sources.

Data Synthesis: To avoid liability for inadequate or inaccurate documentation, nurses must be aware of the major issues involved in documentation litigation. New technology is altering how healthcare documentation is done and raising new confidentiality issues.

Conclusions: Nurses should follow their facility's guidelines and principles for documentation of patient care, especially when using more advanced technologies.

Implications for Nursing Practice: Educating nurses about the principles of documentation and the importance of implementing risk-reduction practices will help guard against liability and ultimately improve patient care.

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