In nursing documentation, one small error can literally mean the difference between recovery or the worsening of a patient’s health. That’s why nurses need to understand the 5 legal requirements for nursing documentation and avoid making common mistakes that can lead to adverse patient outcomes. But before discussing the requirements, let’s explore nursing documentation itself.
Nursing documentation is the key to all medical and treatment decisions. It acts as written evidence of care delivery and supports the nurse and healthcare provider in their moral responsibilities when caring for patients or residents. Nursing documentation also provides evidence during legal disputes. For these reasons, nursing documentation must be accurate, well-written, and updated at the point of care or shortly afterward to minimize documentation errors.
When patients are admitted to a long-term care provider, such as a nursing home, their medical information is documented in the facility’s senior care software and includes the following information:
- All admissions, discharge, transfer, and transport information
- Patient or resident’s socioeconomic background
- Patient or resident care plan
- All nursing processes and treatments
- Medication administration
- All collaborations between caregivers, including primary carers and other healthcare providers
As nurses play the leading role in caring for patients, many modern healthcare providers and long-term care facilities have adopted the use of nursing computer software, as it allows nurses to streamline and improve nursing documentation processes thanks to:
- Accurate and up-to-date patient or resident information at the point of care
- Quick access to patient records resulting in improved care coordination and efficiency of care
- Secure sharing of patient or resident records between caregivers via the cloud-based electronic systems
- More accurate and effective resident diagnoses that reduce medical errors and result in improved care
- Improved patient and caregiver interaction thanks to easier communication
- Safer and more reliable electronic medication prescribing (ePrescribing)
- More legible, accurate, and complete documentation to enable streamlined coding, billing, and reimbursements
- Enhanced security and privacy of resident data
- Improved workflow productivity and efficiency for caregivers to meet their goals and targets
- Reduced costs through less paperwork
Due to the sensitive nature of the healthcare industry, nursing documentation must be standardized with specific legislation in place to ensure that care is adequately and accurately recorded. So let’s look at some legal requirements next for nursing documentation.
Nurse Documentation: 5 Legal Requirements
Now that we have a better understanding of nurse documentation, let’s look at the 5 legal requirements for nursing documentation that facilities must follow:
- Nursing documentation is to be centered around nurse assessments and the planned care that should occur.
- Nurses and other caregivers must document changes in a patient or resident’s health conditions and new actions, such as new treatments or medication. The nurse documentation should reflect all previous conditions and treatments and any new treatments.
- If a patient or resident needs continuous care, arrangements must be made to ensure their medical records are updated regularly to reflect the care and treatments provided.
- While nurses must uphold patient confidentiality, there may be times when they need to disclose certain information when, for instance, emergency treatment is needed. The best way for nurses to maintain confidentiality is to ask for permission from a patient or resident to share their protected health information (PHI), which is governed by the HIPPA Privacy Rule. This gives patients rights to their personal health information and ensures they only have to disclose personal health data in the case of emergencies.
- As mentioned earlier, all documentation in nursing must be accurate, clear, and legible. For this reason, modern healthcare providers opt to use computerized nursing documentation rather than handwritten documentation to ensure the accuracy of notes.
When nurses follow these 5 legal requirements for nursing documentation, they will not only protect themselves and the facility from liability cases, but they will also be able to provide the highest quality of care to their residents.
Contact us here to learn how our long-term care software can improve your nursing documentation.
Nursing Documentation Guidelines: Do’s and Don’ts
Improper nursing documentation can lead to liability and malpractice lawsuits, which damages both a nurse’s and a facility’s reputation. That’s why we will share nursing documentation guidelines that can help prevent medical errors while promoting exceptional patient care. Let’s start with some Do’s for documenting care.
- Ensure all nursing documentation follows the correct nursing process and is within the nurses’ professional capabilities.
- Before entering any form of notes, medication, or treatments into a patient’s medical record, ensure that the correct patient chart is used.
- Ensure that complete descriptions are entered, including patient information on their background, nursing history, assessment forms, personalized nursing care plan, and progress notes.
- Enter the time when medication is administered, who administered care, and the patient’s response to treatment.
- Record and transcribe any phone calls between caregivers regarding the patient, including the time of the call, message, and patient response.
- If a patient refuses treatment or medication, ensure this is documented and reported to the floor manager and physician working the shift.
- Chart at the point of care to ensure all entered details are correct.
- If additional nursing notes need to be added, chart this information with a notation of the date and time, so other caregivers know it’s a late entry.
The 5 legal requirements for nursing documentation mentioned earlier are a good starting point for nurses to improve their charting. However, if nurses want to avoid liability and malpractice lawsuits while reducing adverse patient outcomes, they should also avoid these nursing fundamental mistakes:
- Do not assume the same abbreviations or shorthands are used in every institution. Caregivers have been educated and trained in different institutions across the country. This means they may be accustomed to acronyms that might not be recognized in another state or facility. So to avoid any confusion, do not use abbreviations or shorthands that are not widely accepted.
- Never chart a patient symptom, such as “c/o pain,” without charting how the symptom was treated.
- Never change a patient’s record. It is a criminal offense to alter a patient’s records. Therefore, once a note has been added, it cannot be changed or deleted. Instead, if additional information is needed, a nurse can attach a side note to the patient’s record.
- Do not write unclear or vague descriptions, such as “bed soaked” or “a large amount.” When writing nurse documentation, be precise, objective, and accurate.
- Never chart for a colleague or chart based on what someone else has seen, heard, felt, or said. If necessary, quotations can be used to attribute any remarks made by other caregivers.
- Do not chart ahead of time. A patient or resident’s condition can change unexpectedly. Therefore, charting must be done in real-time rather than ahead of time or later to ensure accurate records.
Though it may seem like there are a lot of rules and regulations to follow, most are common sense best practices that, if a nurse can work them into their daily routines, will provide a safety net for themselves to avoid legal disputes.
Additionally, suppose nurses want to improve their nursing documentation practices. In that case, there are several online documentation in nursing PDF resources they can turn to, such as:
- ANA’s Principles for Nursing Documentation
- Accurate and Legal Documentation
- Professional Documentation: Safe, Effective, and Legal
- Documentation by the Nurse
- Efficient and Effective Documentation in Nursing Care
Why Nurses Must Adhere to the 5 Legal Requirements for Nursing Documentation
While nurses must adhere to the 5 legal requirements for nursing documentation to avoid malpractice lawsuits, it is equally important to recognize that residents also enjoy health benefits as a result of this. This is why modern healthcare providers have integrated senior care software with advanced automation tools that can streamline documentation, resulting in more accurate nursing documentation.
Some of the most significant advantages of using an effective long-term care EHR include:
- Easy access to resident information because caregivers can use multiple connected devices to access resident notes within the facility via the cloud-based system
- Automatic patient data transfers between care plans and notes, allowing caregivers to link medical notes with resident care plans
- Enhanced protection of electronic health records, preventing caregivers from erasing or modifying already recorded patient data
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