What is the role of documentation in Nursing?
Columbus City Schools
This article will explain the importance of providing correct and accurate
Documentation by giving an example of why proper documentation is important for improving the patient care, and in important for the healthcare professional to continue providing a standard level of care, and how documentation can be useful to the person that is trying to prove their case of showing negligence, and how it is also very important and useful for the Nurse to prove that they are giving proper care just in case anyone tries to say, or prove otherwise.
Explains what could ultimately happen as a result of not documenting correctly and gives a very clear and concise definition of professional negligence, as a failure to provide the standard of care to a patient resulting in injury or damage to the patient, and how not documenting pertinent information can lead to a lawsuit by a person (plaintiff) alleging neglect. The four elements a plaintiff needs to prove in order to prove negligence our described and outlined in detail, but most importantly explains that by having accurate and correct documentation can save you the headache of a lawsuit.
After having a very hard day at work, you wreck your brain trying to remember “Did I
document everything I needed to”. You can’t remember if you documented what was
prescribed by Dr. T, or all your many attempts to reach patient B’s healthcare provider, so when you return to work in the morning your desperately running to find the
documentation you left yesterday, hoping and praying that you didn’t leave anything out.
No matter how experienced you are this can happen to you if you’re not careful, and
incorrect or inaccurate documentation can mean serious trouble for the patient, and a...