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Your choice: documentation or litigation?

Lawrence H Plawecki, Henry M Plawecki

    Journal of Gerontological Nursing
    |September 29, 2007
    PubMed

    Related Concept Videos

    Legal Guidelines for Documentation01:06

    Legal Guidelines for Documentation

    The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
    Methods of Documentation V: CBE01:23

    Methods of Documentation V: CBE

    Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
    In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
    Methods of Documentation VI: Case Management Model01:15

    Methods of Documentation VI: Case Management Model

    The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
    For example, a patient with a chronic illness...
    Introduction to Documentation and Reporting01:20

    Introduction to Documentation and Reporting

    Documentation is the systematic process of formally recording, maintaining, and communicating information.
    Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
    Documentation maps the patient's health journey by creating a comprehensive and precise...
    Decision Making: Traditional Method01:14

    Decision Making: Traditional Method

    The process of hypothesis testing based on the traditional method includes calculating the critical value, testing the value of the test statistic using the sample data, and interpreting these values.
    First, a specific claim about the population parameter is decided based on the research question and is stated in a simple form. Further, an opposing statement to this claim is also stated. These statements can act as null and alternative hypotheses, out of which a null hypothesis would be a...
    Methods of Documentation IV: Focus Charting01:26

    Methods of Documentation IV: Focus Charting

    Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
    It typically involves three columns for recording information: