Documentation Article
Sierra N McAllister
East Tennessee State University
Nurses, doctors, respiratory therapists, and many other healthcare workers must chart information on numerous patients every day. Any one of these health care providers could be taken to court. How do healthcare works keep themselves safe in court? The answer was to the statement is proper documentation. In the article titled, “Stay out of court with proper documentation,” the author Sally Austin, RN, gave many examples of what to do and what not to do when charting. Negligence is a common law suit brought upon healthcare professionals. She further goes on to define negligence as, “ . . .failure to provide the standard of care to a patient, resulting in …show more content…
When nurses are charting they should remain objective, and they should always be sure to directly quote patients, compared to describing the patient’s behavior. The author also states that healthcare professionals should document their findings as soon as they do their assessments and treatment. The quicker information is documented, the more accurate the chart will be. Space should not be left in the medical record; this can be avoided if healthcare workers document as soon as they do something for/to the patient. She continues on to say that we must follow our facilities policies on documenting, but we should take extra steps to protect our names during a lawsuit. Healthcare professionals should never document adverse events in the medical record. It is very important to fill out an incident report, though. Most of the time this incident report will go on to risk management, so this incident can be avoided in the future. The author concludes the article by giving sample cases and the outcomes. She also tells us as healthcare professionals to think like a jury, look for red flags, and always document immediately and accurately in order to be protected in the
Sierra N McAllister
East Tennessee State University
Nurses, doctors, respiratory therapists, and many other healthcare workers must chart information on numerous patients every day. Any one of these health care providers could be taken to court. How do healthcare works keep themselves safe in court? The answer was to the statement is proper documentation. In the article titled, “Stay out of court with proper documentation,” the author Sally Austin, RN, gave many examples of what to do and what not to do when charting. Negligence is a common law suit brought upon healthcare professionals. She further goes on to define negligence as, “ . . .failure to provide the standard of care to a patient, resulting in …show more content…
When nurses are charting they should remain objective, and they should always be sure to directly quote patients, compared to describing the patient’s behavior. The author also states that healthcare professionals should document their findings as soon as they do their assessments and treatment. The quicker information is documented, the more accurate the chart will be. Space should not be left in the medical record; this can be avoided if healthcare workers document as soon as they do something for/to the patient. She continues on to say that we must follow our facilities policies on documenting, but we should take extra steps to protect our names during a lawsuit. Healthcare professionals should never document adverse events in the medical record. It is very important to fill out an incident report, though. Most of the time this incident report will go on to risk management, so this incident can be avoided in the future. The author concludes the article by giving sample cases and the outcomes. She also tells us as healthcare professionals to think like a jury, look for red flags, and always document immediately and accurately in order to be protected in the