nursing documentation Archives - Med League Legal Nurse Consultant

Charting By Exception…a Trap for Poor Documentation?

Feb 03, 2014 by ArtiModi

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Charting by Exception is a commonly used and sometimes misunderstood form of documentation. This blog post explains the advantages and disadvantages of this type of charting. A patient’s medical record serves many purposes including: Clearly documenting a patient’s condition Clearly recording [...]

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Medical records Nursing malpractice

Top 12 Holes in Nursing Documentation

Nov 29, 2012 by ArtiModi

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Top 12 Holes in Nursing Documentation Attorneys and expert witnesses review nursing documentation to evaluate how the standard of care was fulfilled. They may ask: • Did the nurse collect the appropriate assessment data? • Did he or she identify [...]

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Communication skills Medical records

Nursing documentation: if you didn’t chart it you didn’t do it

May 25, 2011 by ArtiModi

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Missing Nursing Documentation “If you didn’t chart it you didn’t do it.” In the medical legal world, this expression engenders more fear in nurses than almost any other phrase as it is used to reiterate the importance of documentation. The [...]

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Medical records Medication errors Nursing malpractice

Top 4 reasons why there is gold in nurses’ notes

May 23, 2011 by ArtiModi

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1. Comprehension: Nursing documentation is often the key to understanding the events that spawn a nursing or medical malpractice claim. The medical record can refute or support the plaintiff’s or defendant’s version of events. 2. Screen cases: Careful scrutiny of [...]

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Charting By Exception…a Trap for Poor Documentation?

Top 12 Holes in Nursing Documentation

Nursing documentation: if you didn’t chart it you didn’t do it

Top 4 reasons why there is gold in nurses’ notes

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