How Can You Be Sure that Your Documentation is Satisfactory?

Although we have only looked at three legal cases here, it bears repeating as we conclude our program on defensive documentation that we need to review our own notes to determine whether we are meeting the standard for what is considered satisfactory documentation within our respective employment facility.

There are several key words that come to mind. You might want to write them down on a note card, laminate it and carry it in your pocket. Pull the card out of your pocket periodically and use it to review and evaluate your own documentation. Here they are in alphabetical order:

As stated previously in this program, how you chart is as important as what you chart. Therefore, chart only what you see, hear, feel, measure and count, not what you suppose, infer, conclude or think.

What Does the Future Hold for Nursing Documentation?

Word is out that the future may hold a national standardized medical record or chart format no matter where care is delivered. The result would be standardized documentation systems so that nursing employees would not have to learn a new or different system every time they changed jobs or transferred to a different position within the same facility. Imagine it! Even if you crossed state lines, you would see the same familiar chart format and standard method for charting.

The benefits of charting the same way no matter where you are seems fairly obvious. Hopefully, documentation would be even more accurate and complete wherever and whenever it is written. It also stands to reason that if you continue to use the same charting system, your documentation expertise should continue to improve. So here's to the next charting millennium where this writer hopes that you will keep documentation standards of care uppermost in your mind as you go about your daily work as a dedicated health care professional.

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