Last Updated | November 1, 2024
Record-keeping is crucial for every healthcare facility, and it has become a fundamental part of nursing and all other medical care professionals. An accurately maintained record of patient monitoring is essential because it contributes to information circulation and seamless nursing management and healthcare services.
Legally speaking, accurate documentation in nursing protects nurses and other healthcare professionals from potential lawsuits. A proper record serves as evidence to protect the healthcare provider whenever a legal defense is required. It delivers practicing proof and indicates a professional approach towards patient care.
5 legal requirements of Nursing Documentation
Let’s take a look at the 5 legal requirements for nursing documentation.
What Is The Purpose Of Legal Documentation In Nursing?
Usually, following proper guidelines for documentation in nursing protects them from legal actions.
However, there are other purposes of legal documentation in nursing as well, such as:
- Communication: This is the fundamental purpose of nursing documentation. It allows communication between healthcare professionals and offers continual and consistent support around the clock.
- Quality Assurance: Nursing documentation is a crucial tool for quality assurance in healthcare, acting as an audit to validate the quality of care.
- Legal Responsibility: It functions as a legal document and can be significant evidence in a court of law if legal actions are taken against the healthcare facility.
- Reimbursement: Legal documentation in nursing helps in reimbursements. It’s like a review of patient’s records and treatment that insurance companies ask for.
- Diagnosis and Research: Proper documentation helps with patient diagnosis and selection of the most suitable treatment. Additionally, it can also stimulate healthcare and nursing research.
- Assessment and Evaluation: Healthcare providers and nurses can collect assessment data and treatment progress from these documents, which can be evaluated through the record.
- Education: The nursing documentation can be utilized and read by the residents and medical students for educational purposes.
- Statistics: Legal documentation in nursing helps monitor patient records while reporting and registering vital statistics.
- Healthcare Planning: The patient record will be used to document the country’s common health issues and provide a baseline for national, state, international, and local healthcare planning.
What Is Computerized Documentation In Nursing?
Computerized documentation in nursing is a crucial factor in clinical documentation; however, it still lacks quality and effectiveness. Following legal guidelines for nursing documentation and automated data entry can support and improve quality in such a scenario. They offer completeness, quality, and improved formal aspects of the information.
When it comes to computerized documentation, optimizing the medical device’s UX design also plays an essential role. A well-designed computerized documentation system promises document security while enhancing usability.
Computerized documentation in nursing involves entering patient information through computers and includes vital signs from health monitors, clinicians, and nursing assessments.
Other advantages of computerized documentation in nursing are:
- Standardization of the charting processes and data elements to save time.
- Eliminating the chances of redundancy while removing assessment errors.
- Access to clinical information, improving decision-making time and productivity.
- Improved legibility of the records.
- Reduces the space requirements for storing the patient’s medical records.
- Computerized documentation for nursing helps maintain patient data confidentiality.
What Types Of Documentation In Nursing Use Computerized Systems?
Charting By Exception
It is defined as variance charting and focuses on documenting unusual findings or anything that is not confined by the norms of healthcare practices. It is a short-term method for documenting routine care and conclusions based on the pre-established criteria and set standards for nursing and related interventions. This documentation method reduces the chances of errors in patient care.
These standards also provide the infrastructure for routine healthcare for the clients. Primarily, charting by exception is established on clinical pathways, flow sheets, and care maps designed according to pre-established processes and protocols. However, additional documentation might be required when the patient’s condition is different or deviates from the set standards.
Telepractice Documentation
Nursing telepractice covers different nursing services and care delivered from a distance. It includes nursing provided through videoconferencing or calls from a hospital facility to a remote area. In addition, nursing documentation also covers consultations for public health agencies and insurance companies.
Email Documentation
Healthcare professionals and organizations widely use email for convenience, accessibility, reliability, and speed. However, there is always a risk of privacy breaches and miscommunication. Computerized documentation in nursing can avert this risk.
Guidelines for Documentation in Nursing With EHR
EHR management systems are a major part of healthcare facilities due to the digitalization of records. It follows certain protocols that must be met while entering nursing records as well, for example:
- The documentation needs to be concise, legible, and clear.
- There must be accurate information about the actions taken, assessments, treatment outcomes, complications, risks, reassessment processes in treatments, and changes in the treatment.
Healthcare organizations must ensure they meet the standards and legal requirements for documentation and support the workforce by providing correct information. In addition to adding the patients’ records, the EHR management systems should help in describing the roles and responsibilities of the healthcare staff so there is accountability for actions.
Moreover, an EHR system must outline the need for documentation (when required) along with the resources and checklists supporting the nursing documentation. Clinical technologies and information systems play a crucial role in improving the quality and safety of patient information.
The EHR must have fields that include patient health information, such as diagnoses, medical history, vital signs, patient demographics, allergies, lab reports, vaccinations, and billing data to record all details accurately. You can consider EHR to be a computerized patient file. These management systems are designed to share information with healthcare organizations and providers.
Nursing Documentation Principles
How To Write Nursing Notes Using A Computerized Systems Approach?
The nursing notes provide data and information about the patient’s progress toward developing anticipated results. It includes information about the patient’s problems and the nursing interventions. In the section below, we are sharing the guidelines and factors that must be kept in mind while doing so:
- Do not use abbreviations unless the relative healthcare association standardizes them. Non-standard abbreviations can mean different things to everyone. The patient’s name and other details should be written on top of the document.
- You need to develop and expand the baseline information according to the provided nursing process. The patient’s problems must be identified and managed while evaluating nursing care’s effectiveness.
- The healthcare status should be identified, and problems must be written down to assess the suitable treatment and provide nursing interventions.
- Whenever writing the nursing notes, add the correct time, including the hour, minute, and second. However, the computer system will save you time when updating specific information.
- The documentation must be updated regularly according to progress made in treatment.
How to Write Nursing Documentation With Electronic Health Records?
Nursing documentation supports patient care and improves clinical outcomes and communication. On the other hand, EHRs can improve patient data safety and maximize efficiency.
These systems are designed to streamline documentation; however, their misuse hinders critical thinking, promotes reliance on bypass forms, and increases the risk of errors. So, if you want to write the nursing documentation with EHR correctly, you can follow the steps mentioned below:
- Confirm the suspicions in the documentation and complete all the necessary elements.
- You must identify the errors in the documentation to ensure patient safety and optimize patient care decisions.
- The outcomes of using EHR for nursing documentation must be reviewed to reach the goals. This allows the identification of weak areas for improvements to streamline the documentation.
- The healthcare providers must remain in charge because it allows a follow-up on the nursing process and outlines future clinical documentation practices.
Nursing Documentation Legal Requirements – Process Flow
- Assessment: Start with a detailed evaluation at the beginning of each shift. Get information from handovers, clinical observations, and EHR reviews and document the record in a relevant sheet.
- Planning: Develop a care plan based on the assessment, collaborating with the patient and their family.
- Implementation: Make sure to put all the nursing actions in writing, including medications administered and any changes in the patient’s condition.
- Evaluation: Regularly review and update documentation to reflect ongoing assessments and patient responses to interventions.
5 Legal Requirements for Computerized Nursing Documentation
The healthcare industry is extremely sensitive because one mistake can literally cost someone their life. For this reason, it’s essential to understand the importance of accuracy in nursing documentation.
Here is a list of the 5 legal requirements that must be fulfilled while making computerized nursing documentation:
- The nursing assessment of the patient and the care planned and provided should be added to the documentation.
- If the patient’s condition changes and new actions are taken, the data regarding the condition and treatment should be added (the old data remains the same).
- If a patient needs ongoing care, arrangements must be made to ensure regular updating of the document.
- Nurses should keep patient information confidential. However, if treatment depends on such information, ask the patient for consent before disclosing it.
- The information must be legible, clear, and accurate.
Action Plan to Improve Nursing Documentation
Consistent and accurate nursing documentation validates that treatments and medication protocols are followed properly to deliver proper patient care. It proves that the correct dosages are provided at the right time because the inability to chart the activities will negatively influence patient care.
Here are some ways to improve the nursing documentation:
Determine Correct Text
You must choose the correct text when writing or explaining abnormal findings in the patient’s diagnosis. You must indicate all the crucial parameters and add abnormal findings in the notes section.
Special Waivers & Allergies
In situations where patients refuse to accept the blood transfusion they need, avoid legal liabilities by noting the existing allergies that can influence their health outcomes.
No Advance Charting
Do not chart anything that has not happened to maintain the reliability and accuracy of medical documentation.
Be Cautious In Charting Frequent Patients
Healthcare providers and nurses often attend to the same patient more than once. They must be attentive while providing medical care and make sure they treat real-time complaints while encountering frequent or repeated patients.
Check The Pain Complaints
Any form of pain indicates an underlying problem. So, documentation and investigation are necessary when a patient complains about new pain. They help with making the right treatment calls and can prevent legal actions. Remember that thorough and accurate charting will become the best defense against legal consequences.
Avoid Late Entries
Late entries mean data inconsistencies resulting in treatment inaccuracies and make room for legal action against the facility and the person responsible.
Follow the Policy on Abbreviations
Only use standard abbreviations known by all to avoid any confusion.
How Are Computerized Systems Improving Nursing Documentation And Reducing Risk?
Computerized systems improve nursing documentation by offering quicker access to data, making it more convenient to read than handwritten notes. They reduce the chances of misinterpretation and errors and improve patient care quality.
Secondly, computerized nursing data eliminates the need to store paper files and provides straightforward access to doctors who want it (remote, too). Some healthcare facilities have EHR systems with a patient portal, allowing patients to check their medical information whenever needed.
Smoothly Integrate EMR Solution Into Your Existing System To Make Nursing Documentation Easy
Seamlessly integrate HIPAA-compliant EMR solutions into the existing systems to make nursing documentation efficient and compliant with Folio3 Digital Health. Our dedicated team is available to help you every step of the way.
Conclusion
Following the 5 legal requirements for nursing documentation, namely accuracy, completeness, timeliness, organization, and legibility, helps with effective patient care and protects healthcare providers from legal liabilities. By maintaining precise documentation and abiding by the standard documentation protocols, nurses can ensure patient safety and provide a defense in legal situations.
Frequently Asked Questions
What Are The Methods of Documentation in Nursing?
Nursing documentation can be completed through different methods, such as:
- Charting by exception
- Narrative charting
- DAR Focus charting
- Discharge summary
What is Effective Documentation in Nursing?
Effective documentation delivers information about nursing assessment, including provided care, changes in the patient’s clinical state, and patient data to offer high-quality patient care. Clear, accurate, accessible documentation results in safe, evidence-based nursing practice. The documentation process is also impacted by the system, so always choose the best healthcare mobile app development company in the USA.
How To Document Patient Activity Levels?
The activity level should be documented by entering every entry, date, and time, along with nurse names and roles in the patient’s activities. The activity level must be entered as soon as care is provided.
What Are the Steps Involved in Proper Medical Documentation?
- Mark the entries, time, and date
- Write the healthcare provider’s name and role
- Enter all the entries immediately after providing care
- Always remain legible, objective, and accurate
- Keep a professional tone while writing the documents
- You should only use standardized abbreviations
- The mistakes must be corrected with a single strikethrough (don’t forget to date the corrections)
What Are Nursing Documentation Requirements?
The nursing documents should be:
- Accessible
- Accurate
- Relevant
- Auditable
- Clear, concise, comprehensive, and thoughtful
- Legible/readable
- Aligned with the nursing process
- Retrievable permanently
What Are The Types Of Nursing Documentation?
Most nursing documentation is done electronically in the EMR systems through programs like Epic charting. Nurses follow a few different formats and methods when documenting; common types include:
- Narrative documentation
- Progress note
- Charting by exception
- Situation, background, assessment, and recommendation (SBAR)
- Problem-focused documentation (i.e. SOAP)
About the Author
Abdul Moiz Nadeem
Abdul Moiz Nadeem specializes in driving digital transformation in healthcare through innovative technology solutions. With an extensive experience and strong background in product management, Moiz has successfully managed the product development and delivery of health platforms that improve patient care, optimize workflows, and reduce operational costs. At Folio3, Moiz collaborates with cross-functional teams to build healthcare solutions that comply with industry standards like HIPAA and HL7, helping providers achieve better outcomes through technology.
