Guilty or Innocent: Protecting Your License Through Proper Nursing Documentation

With all the training and education nurses receive, there is little true explanation about the importance of documentation. Even in today’s litigious culture and the backlash of services no longer reimbursable—it is crucial we as nurses understand the rationale for our documentation practices. By creating specific systems to ensure license protection, we in turn provide more effective hand-off communication. Every nurse knows it’s the law and that you don't want to lose your license, but do we really know why the methods of documentation are so vital to our livelihood? Has the electronic medical record made this approach additionally arduous? Do the questions on the EMR provide an accurate picture of the actual care provided? Often times, these reports are not clear or complete.Through fictional and non-fictional stories, Rosale Lobo reveals proper nursing documentation techniques— providing clarity and important best practice concepts that can be applied immediately.Extraneous situations will arise in nursing, making it imperative to develop intentional methods of documentation. By putting together an effective system you will decrease your chances of being sued. For the future of nursing documentation, the EMR is not the answer, a personal system of accountability is.