Nurses create and edit patient records many times during any work day. We may even complain that we spend more time charting than we do with our patients. Although that may be true, we should remember that patient care isn’t just “hands-on.” Documentation in nursing is also an integral part of providing quality and safe care to our patients.
The Importance of Documentation
We learn in nursing school that a patient record is a legal document. We also learn that “if it isn’t charted, it isn’t done.” We should consider these facts in practical terms and not just as something our instructors repeated numerous times.
The standards of nursing care include the principle that any of your coworkers should be able to pick up a chart and understand the status of that patient’s condition and care. This is importance since quality care is a team effort. The team must be able to work together and ensure that each patient’s individual needs are clearly communicated to each other.
Another issue with regards to documentation is financial reimbursement. Third party payers evaluate the documentation in a patient record to determine whether payment is appropriate.
Documentation and the medical necessity of treatment are closely scrutinized. At times, payment may be denied. We cannot forget that healthcare is a business. Funding for facilities can determine the types of care that can be offered, the numbers of staff employed, etc., thereby also potentially impacting quality of care.
Avoid Getting in Trouble with the Law
Potential litigation is an issue that we would probably rather not consider, however a patient record may form the basis for the filing of a lawsuit against medical malpractice. Typically, in litigation, the record is reviewed by an “expert” working for the plaintiff’s attorney. He or she will render an opinion on the quality and appropriateness of the care provided.
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