Improper documentation can open up an employer to liability and malpractice lawsuits, while proper nursing documentation helps prevent medical errors and promotes the delivery of high-quality patient care. Attorney General Maura Healey is the chief lawyer and law enforcement officer of the Commonwealth of Massachusetts. 3. Here are some good tips to follow when charting: Do's . If it is meticulous, appropriate and truthful, it supports quality medical care. Requirements for quality documentation The following principles are intended to provide nurses and midwives with clear direction for producing and maintaining high quality, defensible documentation: 1. As a Legal Document. Be Accurate. Cost: $30. Nurses are highly accountable to patients, the public, employers, and the entire profession. Underwood, R. A. Whether nursing documentation is paper-based or electronic, the requirements remain the same; clear and concise patient care information, reflecting responsible professional judgment, signed, time-stamped, and dated within an appropriate time frame (ANA, 2015). Resources. • Documentation can determine the amount of Medicare/Medicaid money a facility receives for the care given to a particular resident. Before entering anything, ensure the correct chart is being used ; Ensure all documentation reflects the nursing process and the full extent of a nurse… LICENSURE REQUIREMENTS CHECKLIST (Listed below are the minimum requirements needed to obtain a registered and/or practical nurse license and specialty certifications.) Documentation Guidelines for Registered Nurses Documentation and record keeping is a vital part of registered nursing practice. Documentation also provides data for research and workload management, both of which have the potential to improve health outcomes. The nursing home can be fined for lack of documentation by the State and may even suffer legal ramifications from lawsuits. issues that may impact on nursing practice 3.5 Develop and implement strategies to resolve ethical issues within practice 3.6 Take responsibility for addressing ethical issues and legal requirements in line with own nursing role 3.7 Complete all documentation in accordance with state/territory legislation and organisation policies and Professional and legal standards: Documentation is a comprehensive record of care provided to a client. Clifton Park, NY: Delmar Learning. A. Good quality record keeping is linked with improvements in patient care, while poor standards of documentation are regarded as contributing to poor quality nursing care. Under the National Law, the Nursing and Midwifery Board of Australia and Ahpra work in partnership to implement the National Scheme, each with specific roles, powers and responsibilities set down in the National Law. Based upon the legal guidelines for documentation, which of the following corrective action is incorrect? Learn to implement critical nursing documentation skills to prevent mistakes throughout the health care process, support heath care providers and demonstrate a high level of patient care. Complying With Medical Record Documentation Requirements MLN Fact Sheet Page 3 of 7 ICN 909160 April 2017. Documentation is therefore a means for others to assess whether the care that a patient received met professional standards for safe and effective nursing care, or not. ... Sign each block of charting with full legal initials and title. It can be helpful to keep these in the back of your mind as you go about your scrivener responsibilities. Nursing Homes. Please note, however, that if an employee were to take unpaid leave under the FMLA, the FMLA’s documentation requirements are different and apply. Proper and accurate documentation is essential to avoid types of nursing documentation errors, and for helping to avoid patient deaths or increased liability for the caregiving facility, physician, or nurse. Explain nursing documentation requirements for specific aspects of care, including critical diagnostic results, medications, non-conforming patient behavior, pain, patient and family involvement in care, restraints, and prevention of falls, infections, pressure ulcers, and suicide. Describe recommended documentation practices concerning communication with the patient’s Australian Health Practitioner Regulation Agency. LEGAL ASPECTS OF NURSING DOCUMENTATION: THE 25 DOs AND DON'Ts OF NURSING DOCUMENTATION I. 6. Nursing Documentation Tips The following tips, recommendations, and best practices can ensure your documentation is as precise and useful as possible. File a complaint, learn about your rights, find help, get involved, and more. 14. 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