OSM560-April_DIGITAL_rev_Layout 1 4/8/13 11:07 AM Page 34
MEDICAL MALPRACTICE
You may have to stay long past your shift to get all this documentation completed, but when the time comes to explain what you did,
you'll be glad you took the time to document. Take credit for the great
care you provided and get it in the chart.
The crucial question to keep in mind at all times needs to be, "How
does my documentation support the actions I took to care for this
patient?" If you did all you could for a patient, the documentation
should reflect that. And that level of thoroughness just might save you
a whole lot of trouble later on. OSM
Ms. Kleinhesselink (jkleinhess@lincolnsurgery.com) is the chief quality officer
and Ms. Lester (clester@lincolnsurgery.com) is the chief clinical officer of
Lincoln Surgical Hospital in Lincoln, Neb.
3 4 | O U T PAT I E N T S U R G E R Y M A G A Z I N E | A P R I L 2 013
