In addition to documentation by physicians, nurses’ documentation affects patient safety, reimbursement, risk management, and more, so it’s important that everyone work toward thorough and accurate documentation. The following pointers are useful ideas to help your nursing staff improve their documentation:
- Train immediately-At the point of hire is a good time to explain the expectations for documentation and the legal ramifications of inadequate documentation. In some facilities, new nurses go through an orientation and are buddied up with another RN. During orientation, trainers go through nurses' notes, assessment, daily care records, and medication records.
- Provide ongoing feedback-Use case studies for annual updates. It's also useful to provide feedback after documentation to be sure nurses change the way they document when necessary. In addition to an annual program, some hospitals discuss documentation problems during staff meetings or quarterly nursing-rounds case studies.
Editor's note: The above excerpt is from the online course, "Nursing CE Series: Nursing Documentation - Reduce Your Risk of Liability." Check out our latest nursing resources here.