What is documentation in Nursing Practice?
Documentation is any written or electronically generated information about a client that describes the status, care or services provided to that client. Through documentation, you communicate observations, decisions, actions and outcomes of these actions for clients, demonstrating the nursing process.
How much time do nurses spend on documentation?
A study published in the journal CIN: Computers Informatics Nursing in 2012 found that nurses at 55 hospitals spent 19% of their time on documentation, whether they used paper records or an EHR. “It’s probably worse now,” said Carol Bickford, a senior policy fellow at the American Nurses Association.
How is a nurse’s documentation used in a lawsuit?
The nurse’s documentation is read by lawyers and experts when a lawsuit ensues. Every microscopic detail of the medical record is examined by the lawyers and the expert nurses that they employ to make a case for their side. They’re looking to see what went wrong and what could have been done better.
Why does a nurse need to document everything?
The nurse is also documenting for her own purposes. Documentation that’s complete and accurate can also serve as a memory refresher when details are unclear or forgotten. Accurate and complete documentation is also important for any potential subsequent litigation.
Why do nurses document their work and outcomes?
Nurses document their work and outcomes for a number of reasons:the most important is for communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities.
What does the nurse have to sign for?
The nurse must always sign for every notation in the client’s record and for action, such as recording or receiving physician’s orders.
What are some tips for jotting down notes in hospital?
Another tip worth mentioning is if you’re jotting down notes is to buy your own pen. I recommend this for several reasons: You don’t have to rely on the hospital to provide this (you might have to hunt one down, or the one they have is not very good). You can make sure you’re using a “click” pen.