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Is your nursing license at risk because of poor documentation?

Throughout your nursing training, you probably heard of countless occasions of the importance of accurate patient documentation. Not only does careful recording of your observations and actions provide your other team members with a roadmap of your patient's care, it also provides a log of treatment that can be presented to defend you and your co-workers from accusations of substandard care.

Precise documentation goes beyond repairing illegible handwriting, spelling mistakes and grammatical errors, although avoiding these is recommended for more professional documentation. More important, however, is the accuracy and promptness with which you complete your records. In fact, your notes and observations on the care you give to your patients may be all that stands between you and a license suspension or successful malpractice lawsuit.

If you didn't document it, you didn't do it

Documenting the care you give and the changes you observe in your patients is critical, so much so that failing to carry out this duty may result in charges of unethical behavior. You certainly know the importance of recording medical events, the administration of drugs and the observation of vital signs as soon as possible. Waiting hours or even days after the event risks the possibility of misremembering or forgetting altogether.

Nurse advocates urge professionals to develop the habit of documenting consistently and automatically, using methods of the highest quality and keeping the following in mind:

  • Abbreviations, jargon and acronyms may be confusing to other professionals or those without medical training.
  • Vague terms like "small" or "some" as they are more difficult to interpret than precise measurements or specific details.
  • It is not necessary (or advisable) to record your opinion of a situation or to include more than facts and your observations in your narrative.
  • Patient documentation is not the place to vent frustration or conflict with others on your team.
  • Any documentation you make should refer only to care that you performed, never to actions someone else performed or actions you did not take.

Recording observations or behaviors of other staff members, or falsely documenting care you did not give, may lead to serious legal and ethical issues. Your record keeping may be judged fraudulent, placing your license - and perhaps your freedom - at risk.

When nurses find themselves facing such consequences, they may have many questions and concerns. Fortunately, if you are in such a situation, you can seek legal advice from a Tennessee attorney who has successfully defended the licenses and livelihoods of many other professionals.

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