What is documentation in nursing?

Documentation is a core nursing competency, which helps to ensure that patients receive appropriate, high-quality health care services.

What is defensive documentation for nurses?

Defensive Documentation Can Help Protect Nurses from Liability In a litigious and ever-shifting healthcare landscape, nurses face potential liability in their everyday work.

What are the nursing documentation competencies required by the Ana?

Nurses must also be familiar with the ANA’s Scope and Standards of Practice (2015) which outlines the required competencies of nursing documentation utilizing critical thinking and the nursing process. The standards state that nurses must document the following: Relevant data accurately and in a manner accessible to the interprofessional team;

Do nurses complete documentation retrospectively without knowing when care was completed?

A study at a large acute trust in England, which was led by researchers in Nottingham, found nurses sometimes completed documentation retrospectively without full knowledge that care had actually been completed.

Documentation encompasses every conceivable form of recordable patient data and information, from vital signs to medication administration records to narrative nursing notes. Documentation is a legal record.

Will your nursing documentation come back to haunt you forever?

Here’s a piece of good news: even though your nursing documentation will become a part of your patients’ permanent medical records, you don’t have to worry about if or how that documentation could come back to haunt you forever, at least from a legal point of view. The statute of limitations for most medical malpractice cases is two years.

Do nurses experience barriers to maintaining accurate documentation?

However many nurses still experience barriers to maintaining accurate and legally prudent documentation. A review of nursing documentation of patient care and progress towards achieving outcome goals in our organisation identified a lack of clear and easy to follow information about the patient’s progress.

What are the Ana standards of practice for documentation?

Standards of Practice to ensure that they are demonstrating contemporary professional nursing care. The ANA standards identify the following characteristics for effective documentation: • Accessible • Accurate, relevant, consistent • Auditable