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Browsing all articles in Documentation

Questioning a Doctor’s Order

It is your right—and your responsibility— to question any order that you think may be inappropriate. While looking out for your patients' best interests, never shrug off a dubious order, trusting that “the physician knows best.” Staying quiet could be viewed as negligence, leaving you, your nursing program (if you are a student) and the facility vulnerable to a malpractice charge. During the course of a hectic day it's human nature that you may not always trust your judgment, but following through on your concerns will help you gain confidence in your competence and professionalism, as well as protect you against liability. Read more »

Avoid Haunting Documentation

The words you choose in charting today could come back to haunt you tomorrow. Some-times, seemingly harmless bits of information you write in a patient's medical record can hurt you in a lawsuit. Read more »

Good documentation can help you defend yourself in a malpractice lawsuit, as well as a being a huge factor in keeping you out of court. It is imperative to ensure  documentation is complete, correct, and timely. If not, it could be your demise, being used against you in a lawsuit. Read more »

Defensive Documentation


When documenting the patient's care in a  chart, you are communicating with other members of the healthcare team, as well as contribute to a legal document: the medical record. What you write (and sometimes what you don't write) reflects the quality of  care provided. In a malpractice suit, good charting can be a primary defense. Careless, inaccurate, or incomplete charting can hurt you in court. Read more »

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