Discuss the correct way of charting in a patient's record. Analyze the impact of poor documentation in patient care? Give one or two examples. Explain possible legal concerns for poor documentation.
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Documentation in a patient record first must be clear, correct and concise. If the caregiver charts immediately, the information the nurse will remember more details. It is always important to chart as soon as possible after any event. With the advent of electronic documentation, the nurse or caregiver is able to go into the system immediately and chart medication by bar-coding systems. Electronic charting assists with not only better medication recording but will remind the nurse to when it is time for procedures to be done. With so many things to remember, it is one thing that helps us with accuracy.
When a nurse receives a new patient, the patient should have an assessment as soon as possible ...
The expert discusses the correct way of charting in a patient's record. The impact of poor documentation in patient care is analyzed.