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What Are The 5 Legal Requirements For Nursing Documentation?

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    Posted in Electronic Health Records

    Last Updated | August 24, 2022

    Record-keeping is crucial for every healthcare facility, and it has become a fundamental part of nursing and all social care professionals. An accurately maintained record with every detail about patient monitoring is essential because it contributes to information circulation and seamless nursing management and healthcare services.

    Legally speaking, record-keeping and documentation are great ways of protecting healthcare professionals and nurses. That’s because a proper record helps protect the healthcare provider whenever a legal defence is required. Not to forget, it delivers practicing proof and shows off professionalism. If you want to know more about nursing documentation, we’ve got it all in this article!

    What Is The Purpose Of Documentation In Nursing?

    As already mentioned in the introduction, proper documentation is essential for keeping records of the patients while legally protecting the nurses. However, there are other purposes of documentation in nursing, such as;

    • Communication– this is the fundamental purpose of nursing documentation because it allows communication between healthcare professionals to offer continual and consistent care around the clock
    • Quality Assurance– the nursing documentation helps keep an eye on the healthcare quality. It can provide validation of the quality of care because it acts as an audit.
    • Legal Responsibility –the nursing documentation works as a legal document because it can be significant evidence in the court of law if there are legal actions taken on the healthcare facility
    • Reimbursement –it works as reimbursement for patient care because it’s a review of patient’s records and treatment (insurance companies might ask for it)
    • Diagnosis & Research– proper documentation helps diagnose the patients and select the most suitable treatment. Moreover, it can give a push to healthcare and nursing research
    • Assessment & Evaluation –the healthcare providers and nurses can collect the assessment data from these documents. In addition, the treatment progress can be evaluated through the record.
    • Education –when the nursing documentation is no longer have to be stored, it can be utilized and read by the residents and medical students for educational purposes
    • Statistics –the nursing documentation will help keep an eye on the patient records while reporting and registering the vital statistics
    • Healthcare Planning — with the patient record in documentation, the country’s common health issues will be determined, and it also provides a baseline for national, state, international, and local healthcare planning.

    What Is Computerized Documentation In Nursing?

    Computerized documentation in nursing is a crucial factor of clinical documentation. However, it’s widely seen nursing documents lack quality and effectiveness, but computerized documentation can support and improve quality. This is because these computerized documentations promise completeness, quality and improve the formal aspects.

    When it comes down to computerized documentation, optimizing the medical device UX design also plays an essential role. The common function is said to be the efficiency in attaining the documents, but a well-designed computerized documentation system promises the security of the documents while enhancing usability.

    Computerized documentation in nursing is defined as the documentation of a patient’s care through computers. For instance, it includes the vital signs from health monitors along with the clinicians and nursing assessments. There are various advantages of computerized documentation in nursing, which include the following;

    • It helps standardize the charting processes and data elements, which eventually saves time
    • It eliminates the chances of redundancy while removing assessment errors
    • It offers access to clinical information, which improves decision-making time as well as productivity
    • The computerized documentation will help improve the legibility of the records
    • It will reduce the space requirements for storing the patient’s medical records
    • Lastly, the computerized documentation for nursing helps improve the confidentiality

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    What Are The Types Of Documentation In Nursing Using Computerized Systems?

    • Charting By Exception 

    This is a documentation method that reduces the chances of errors in patient care and patient treatment outcomes. It is also defined as variance charting and focuses on documenting unusual findings or anything that’s not confined by the norms of healthcare practices. It is a short-term method for documenting routine care and findings based on the pre-established criteria and set standards for nursing and related interventions.

    These standards also provide the infrastructure for routine healthcare for the clients. For the most part, charting by exception is established on clinical pathways, flow sheets, and care maps designed according to pre-established processes and protocols. However, when the patient’s condition is different or deviates from the set standards, additional documentation might be required. However, charting by exception needs the availability of proper clinical pathways, standards, and policies.

    • Telepractice Documentation 

    For those who don’t know, nursing telepractice covers different types of nursing services and nursing care delivered from a distance. For instance, it includes the nursing provided through video conferencing or calls from a hospital facility to a remote area. In addition, this nursing documentation also covers the consultation for public health agencies and insurance companies. The documentation should be ensured when healthcare service or consultation is provided without in-person patient contact.

    • Email Documentation

    Healthcare professionals and healthcare organizations widely use email because of convenience, accessibility, reliability, and speed. However, there are always chances of risks because there can be privacy breaches and miscommunication. With computerized documentation in nursing, the emails must be documented by keeping a copy of emails on the patient’s record. Moreover, you should follow the policies and professionalism while communicating through emails.

    Guidelines for Documentation in Nursing With Electronic Health Records Management System

    EHR Management systems have become extremely crucial for healthcare facilities with the digitalization of records. However, some guidelines must be followed while documenting the nursing records, such as;

    • 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
    • Always meet the medical and legal requirements while writing the documentation

    Healthcare organizations need to ensure that they are meeting the standards and requirements for documentation. For instance, the workforce should be supported to provide correct information documentation. In addition to adding the patients’ records, the EHR management systems should describe the roles and responsibilities of the healthcare staff.

    It must outline the need for documentation (when it is required) along with the resources and checklists for supporting the nursing documentation. Clinical technologies and information systems play a crucial role in healthcare documentation. It is essential to consider the quality and safety prerequisites that might incur while implementing or designing the computerized documentation.

    Every computerized documentation should meet the essential standards and elements of documentation. Not to forget, it must support clinical communication. As far as the EHR is concerned, it needs to include patient health information, such as diagnoses, medical history, vital signs, patient demographics, allergies, lab reports, vaccinations, and billing data.

    Moreover, the EHR is defined as the digital record that delivers health information about patients, and it wouldn’t be wrong to call it a computerized patient file. These management systems are designed to share information with healthcare organizations and healthcare providers. As for the guidelines for creating the documentation, we have mentioned them already!

    How To Write Nursing Notes Using A Computerized Systems Approach?

    The nursing notes are designed to provide data and information about the patient’s progress towards developing anticipated results. It includes information about the patient’s problems as well as the nursing interventions. In the section below, we are sharing the guidelines and factors that must be kept in mind while writing the nursing notes for computerized reports, such as;

    • Do not use abbreviations unless the relative healthcare association standardizes them. This is because non-standard abbreviations can mean different things to everyone. As for the patient’s name and other details, they should be written on top of the document.
    • You need to develop the baseline information and expand it according to the provided nursing process. Moreover, the patient problems must be identified and managed while adding the evaluation of nursing care’s effectiveness
    • The healthcare status should be identified, and healthcare problems must be written down because it helps assess the suitable treatment. In addition, it will help provide nursing interventions.
    • Whenever writing the nursing notes, add the correct time, including the hour, minute, and second. However, the computer system will also save the time you update specific information
    • The documentation must be updated regularly according to the progress in treatment.

    How to Write Nursing Documentation With Electronic Health Records?

    The nursing documentation is responsible for supporting patient care and improving clinical outcomes. In addition, it can enhance communication. On the other hand, the EHRs can support the documentation with information that helps improve patient safety and maximize efficiency. In addition, it helps evaluate the quality of care and determine the staffing needs.

    These systems deliver the standard documentation form that’s shared across the healthcare team. However, if they aren’t used properly, the critical thought processes will be reduced, and they might even start relying on the bypass forms. In addition, it can result in errors as well. So, if you want to write the nursing documentation with EHR correctly, you can follow the below-mentioned tips;

    • Confirm the suspicions in the documentation and complete all the necessary elements
    • You must identify the errors in the documentation for ensuring patient safety and optimizing the patient care decisions
    • The outcomes of using EHR for nursing documentation must be reviewed to reach the goals. In addition, it will allow you to identify the weak areas and make improvements to streamline the documentation
    • The healthcare providers must remain in charge because it allows a follow-up on the nursing process and outline the future clinical documentation practices

    Action Plan to Improve Nursing Documentation

    Nursing documentation is crucial, and that’s the prime reason consistent and accurate documentation is needed from the nurses. This is because it helps deliver proper patient care. The documentation will ensure that you are following the treatments and medications properly. In addition, it ensures the correct dosages are provided at the right time because the inability to chart the activities will negatively influence patient care.

    In addition, it can undermine the professional reliability and credibility of the nurses. It might not sound relevant but hiring one of the best healthcare consulting companies in the USA for the documentation platform is seamless. In the section below, we are sharing the action plan for improving the nursing documentation, such as;

    • Determine Correct Text 

    Whenever you are writing or explaining abnormal findings in the patient’s diagnosis, you must choose the correct text. You must indicate all the crucial parameters and add abnormal findings in the notes section.

    • Special Waivers & Allergies 

    There are always some patients that reduce to accept blood transfusions. However, if you don’t follow the patient’s permission and wishes, it can result in legal liabilities. In addition, if you don’t note down the existing allergies that can influence the health outcomes of patients, it also leads to legal consequences. That being said, always add that information to the documentation

    • No Advance Charting 

    It’s pretty explainable because you shouldn’t chart anything that hasn’t happened. It also includes the symptoms because if the symptom doesn’t exist, you must not write it in the documentation.

    • Be Cautious In Charting Frequent Patients 

    Healthcare providers and nurses are human, and there are chances of repeated patients. These patients can clog the healthcare facility with constant complaints. However, you must be attentive while providing medical care and make sure you don’t implicate while encountering frequent or repeated patients.

    • Check The Pain Complaints

    Whenever a patient experiences pain, it shows that something is wrong with them. So, whenever a patient complains about a new pain, you must document it and investigate it. Careful documentation will eventually help you stay safe from legal actions. Keep in mind that careful and accurate charting will become the best defense against legal consequences.

    Five‌ ‌Legal‌ ‌Requirements‌ ‌for‌ ‌computerized‌ ‌nursing‌ ‌documentation‌ 

    The‌ ‌healthcare‌ ‌industry‌ ‌is‌ ‌extremely‌ ‌sensitive‌ ‌because‌ ‌one‌ ‌mistake‌ ‌can‌ ‌literally‌ ‌cause‌ ‌someone‌ ‌their‌ ‌life.‌ For‌ ‌this‌ ‌reason,‌ ‌it’s‌ ‌essential‌ ‌to‌ 
    ‌understand‌ ‌that‌ ‌nursing‌ ‌documentation‌ ‌holds‌ ‌the‌ ‌patient’s‌ ‌information,‌ and‌ ‌the‌ ‌treatment‌ ‌decisions‌ ‌will‌ ‌be‌ ‌based‌ ‌on‌ ‌that.‌ ‌That‌ ‌being‌ 
    said,‌ ‌there‌ ‌have‌ ‌to‌ ‌be‌ ‌standards‌ ‌and‌ legalizations‌ ‌to‌ ‌ensure‌ ‌the‌ ‌nursing‌ ‌documentations‌ ‌are‌ ‌on‌ ‌top.‌ ‌In‌ ‌this‌ ‌section,‌ ‌we‌ ‌are‌ ‌sharing‌ ‌some‌ 
    legal‌ requirements‌ ‌that‌ ‌must‌ ‌be‌ ‌fulfilled‌ ‌while‌ ‌making‌ ‌computerized‌ ‌nursing‌ ‌documentation;‌ 
    1. The nursing assessment of the patient as well as implied care that was planned and provided should be added to the documentation 
    2. If the patient’s condition changed and new actions were taken about him/her, the information about the condition and treatment should be added (the old data remains)
    3. If a patient needs ongoing care, arrangements must be made to ensure regular updating of the document 
    4. If a nurse has confidential information about the patient, it should be kept confidential. However, if treatment depends on such information, ask the patient for consent before you disclose the information 
    5. The information must be legible, clear, and accurate. In addition, the information added to the computerized nursing documentation must be simultaneous. 

    How Computerized System Improving Nursing Documentation And Reducing Risk?

    The computerized systems can improve nursing documentation by offering quicker access to the updating platform. These computerized documents are actually more convenient to read as compared to handwriting. It will eventually reduce the chances of misinterpretation and errors because it can result in ineffective patient care quality.

    Secondly, there won’t be a need to store the paper files because the computerized documents will be straightforward to access (remote access is also available). Some healthcare facilities also design an EHR system with a patient portal that allows patients to check their own medical information whenever needed. Not to forget, it can save space by reducing the number of files in those cabinets.


    What are the methods of documentation in nursing?

    Nursing documentation can be completed through different methods, such as problem-oriented charting and source-focused charting. There is also a method called narrative charting. Nursing documentation also includes charting by exceptional and critical pathways.

    What is effective documentation in nursing?

    Effective documentation in nursing is all about ensuring seamless clinical communication. The effective documentation delivers information about nursing assessment, including; provided care, changes in patient’s clinical state, and patient data to offer high-quality patient care. Also, the documentation process is impacted by the system, so always choose the best healthcare mobile app development company in the USA.

    How do document patient activity levels?

    The activity level should be documented by entering every entry along with the date and time. In addition, the nurses should add their names and role in the patient’s activities. Not to forget, the activity level must be entered as soon as the care is provided. Still, documenting the patient’s activity level depends on the EHR system that a healthcare facility has deployed. You can also check with HIPAA compliance service providers to obtain the right system for documenting the activity level.

    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)

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