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Nursing Documentation Made Incredibly Easy Fifth Edition

Nursing Documentation Made Incredibly Easy Fifth Edition PDF

Author: LWW

Publisher: LWW


Publish Date: July 31, 2018

ISBN-10: 1496394739

Pages: 312

File Type: PDF

Language: English

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Book Preface

Providing the best care possible for your patients is the most important aspect of nursing. However, nurses find that documentation of that care can be very time consuming, taking time away from the bedside. Yet, documentation needs to be recognized as a crucial part of the health care system. Good nursing documentation clearly and concisely communicates the assessments, actions, and outcomes of care in a timely and accurate manner. Accurate documentation also plays a critical role in acquiring and maintaining accreditation for a facility. However, nurses continually struggle to document in a way that is timely, accurate, and legally prudent.
Although most facilities have converted to using an electronic health record, not all have had that opportunity, and paper documentation still exists. Examples are provided for a paper system because of the great variety in electronic systems and the complexity of utilizing those systems is too difficult to showcase by looking at one screenshot. However, the information presented throughout the book should be reflected in all documentation, whether on paper or electronic.
Nurses experience many barriers to completing documentation in an acceptable way. These include time, care complexity, and institutional policies associated with documentation. Whether you use paper or electronic charting, errors in documentation occur. Each type of documentation has errors specific to the type of documentation and there are errors common to all types of documentation. Learn your documentation system well in order to provide a record that meets professional and legal standards. Always remember, poor nursing documentation can place patients, staff, and organizations at considerable risk of physical and legal harm.
Kate Stout, RN, MSN

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