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MEDICAL MALPRACTICE
and everything within it can be easily located. However, with paper
charts, times and dates can be easily missed, an entry may not be
authenticated with a signature and, let's be honest, there's a temptation to "pre-chart" to make documentation even faster. It's tempting,
but fudging a time here or an action there isn't worth it. A plaintiff's
lawyer will find out.
Support yourself
A final tip: Patient education is a top priority during the patient's stay
at your facility. In your notes, include the date and time of instructions; identify family members or caregivers present; document
knowledge or understanding indicated by the patient; document any
returned demonstrations performed by the patient; and document any
educational materials provided to the patient (booklets, pamphlets,
instruction sheets).
"I don't have time for that kind of charting," nurses might say (with
exasperation, as they juggle a mop, a sick patient, a stack of files and
a cranky surgeon). And, yes, they should take care of patients first.
We all recognize that emergencies happen — requiring rapid, handson responses — leading to documentation written on a paper towel.
Whether you have to document on a paper towel, your scrub pants or
your hand, document the events as accurately as you can. As soon as
possible after the event, when there's time to be clear and thoughtful,
document in the patient record.
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