NFO Business of Medicine Web Series: Checklist for Improving Nursing Documentation and Other Potential Nursing Risks

Documentation in patient health records is used in a variety of ways. It memorializes patient care, facilitates communication among caregivers, forms the basis for coding and billing, provides data pertinent to quality improvement, and may provide information that is critical to the defense of legal action. Unfortunately, nursing documentation issues continue to be a contributing factor in adverse events and malpractice claims. This program addresses common nursing documentation issues and provides realistic strategies to enhance patient safety efforts through documentation. The program will also address additional risks facing nursing today with mitigating strategies. Objectives: Describe the function and benefit of documentation. Identify lessons learned from the defense of claims. Discuss best practices to avoid documentation issues. Establish goals to strengthen documentation. Describe additional nursing risks and mitigation strategies.