Australian Health Practitioner Regulation Agency. Meador, R., Schumacher, M., & Pillemer, K. (2003). If it is meticulous, appropriate and truthful, it supports quality medical care. Documentation is a communication tool that allows RNs and APPLICATION AND FEES Online Application For A Registered or Practical NurseLicense - Complete all fields, answer all questions and upload any supporting documentation. Professional and legal standards: Documentation is a comprehensive record of care provided to a client. Before entering anything, ensure the correct chart is being used ; Ensure all documentation reflects the nursing process and the full extent of a nurse… 6. 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. ... Sign each block of charting with full legal initials and title. Underwood, R. A. Nursing documentation can be a strong evidence to a lawsuit that will help in solving the case. 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. Nurses are highly accountable to patients, the public, employers, and the entire profession. Documentation is not merely “record keeping”; the documentation that comprises a patent’s medical record is also a legal document. Using Medical Scribes in a Physician Practice. Resources. A. Result: In this study, 47.5% of nurses were found to have good nursing documentation practice whereas good nursing documentation was found to practiced on 38.5% of medical records. It can be helpful to keep these in the back of your mind as you go about your scrivener responsibilities. • Documentation is a legal record of care which can be used in a court of law. "Demystifying documentation". The expert CNA’s illustrated guide to documentation. 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. Clifton Park, NY: Delmar Learning. Litigation is already regarded as an occupational hazard for medical staff, and it is estimated that at least one in three other health professionals will be involved in some kind of legal proceedings at some point in their career. With the push to develop and deploy electronic health records (EHRs) and the need for more detailed documentation, there is a growing concern in the medical community regarding the time expended to capture information-electronic or otherwise. Documentation provides a record of the judgment and critical thinking used in professional practice, and provides an account of the nurse’s unique contribution to health care. THIRD-PARTY ADDITIONAL DOCUMENTATION REQUESTS. Based upon the legal guidelines for documentation, which of the following corrective action is incorrect? It is well-known that documenting is one of the most tedious aspects of bedside nursing. All nursing interventions listed in the notes are considered to be accurate and reliable. 3. 14. Many nurses dread documentation because it takes them away from patient care but proper documentation can help nurses avoid medication errors and legal troubles. Never erase entries or use correction fluid. LEGAL ASPECTS OF NURSING DOCUMENTATION: THE 25 DOs AND DON'Ts OF NURSING DOCUMENTATION I. 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. Attorney General Maura Healey is the chief lawyer and law enforcement officer of the Commonwealth of Massachusetts. Be Accurate. File a complaint, learn about your rights, find help, get involved, and more. It can also contradict information found elsewhere in the chart when questions of malpractice or negligence arise. • Documentation can show if a resident is responding well or poorly to their care treatment. Documentation is a legal record. It is imperative they have a sound understanding of various ethical, legal and professional issues they will face during their careers. Complying With Medical Record Documentation Requirements MLN Fact Sheet Page 3 of 7 ICN 909160 April 2017. 13. In the end, your documentation will be better for it. 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. Nursing documentation frequently reflects the most crucial parts of the medical record. Upon request for a review, it is the billing provider’s responsibility to obtain supporting documentation Ethics regards standards of moral judgement and professional conduct. • Documentation can determine the amount of Medicare/Medicaid money a facility receives for the care given to a particular resident. Nursing documentation includes everything involved in the patient’s care: admission history, care plan, progress notes, nursing notes, assessment forms, vital signs, any special flow sheets such as neuro check sheets, restraint forms, code sheets, discharge forms, MAR’s (medication administration reports), etc. Nursing documentation can be accepted in both verbal and written form. Describe recommended documentation practices concerning communication with the patient’s 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. 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