Legal Guidelines for Documentation

Question 1

Accurate Documentation

Answer 1

-best for legal claims
-patient and how nurse followed agency standards​

-Try to chart immediately following care provided​

-IN A COURT OF LAW… “ CARE NOT DOCUMENTED IS CARE THAT WAS NOT PROVIDED” ​

Question 2

Common mistakes=Legal action

Answer 2

Failing to record health information/drugs​

Failing to record nursing actions​

Failing to record medications that was given​

Failing to record drug reactions/ or change in patient condition​

Failing to write legibly or complete​

Failing to document discontinued/refusal medication​

Question 3

Common mistakes=Legal action cont.

Answer 3

Failing to notify Dr., nurse, family and recording exact conversation​

Failing to record a late entry correctly​

Failing to record referrals ​

Failing to record patient teaching​

Question 4

Correcting errors-Paper chart

Answer 4

A single line through entry and your initials (no erasing, “white out”- do not write error or mistake)​

EMR – new entry. Explain error.​

Make sure you have the right chart!!​

Question 5

Late entry-paper chart

Answer 5

Add the entry to the first available line, and label it “late entry” to indicate that its out of sequence, according to facility policy ​

Record the date and time of the entry and, in the body of the entry, record the date and time it should have been made​

Question 6

Late entry-EMR

Answer 6

change date and time and then document. However…