enough to post here. I received it from the Nursing Center
e-News. Feel free to check them out and get yourself added
to the email list. I frequently get really good information and alerts from this source.
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
- How protocols are taking the decisions away from nurses (nursingtrends.wordpress.com)
- Patient Classification Systems Address Nurse Staffing Balance (nursingtrends.wordpress.com)
- Public Health Nursing, Anyone? (nursingtrends.wordpress.com)