What happens if a nurse does not document?

The importance of proper documentation in nursing cannot be overstated. Failure to document a patient’s condition, medications administered, or anything else related to patient care can result in poor outcomes for patients, and liability issues for the facility, the physician in charge, and the nurse(s).

How can a nurse get fired?

The unfortunate truth is that nurses get fired. They can include patient errors, HIPAA violations, causing undue risk for an employer, and social media mistakes. Knowledge is power, and you need to know what may put your employment at risk.

Is documentation important in nursing?

Accurate documentation is essential to maintain continuity and inform health professionals of ongoing care and treatment. It also provides legal evidence.

Why is documentation in nursing so important when thinking about the legal requirements?

Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.

What is considered false documentation in nursing?

Falsification of nursing documentation; unprofessional conduct likely to deceive, defraud or harm the public; and not meeting standards of nursing practice are examples of grounds upon which the board could allege against the nurse managers.

What do nurses get in trouble for?

A DUI conviction or any conviction involving use or possession of drugs and alcohol is considered a violation of the Nursing Practice Act. Misappropriating medications and drug diversion of controlled substances is a serious offense and a violation of the California Nursing Act.

What are the basic rules of nursing documentation?

For documentation to support the delivery of safe, high-quality care, it should: Be clear, legible, concise, contemporaneous, progressive and accurate. Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes.

What are the guidelines for documentation?

7 Guidelines for Documentation in Medical, Aerospace, Defense, & More

• Stay Up-to-Date. No matter how knowledgeable you are, everyone can use a refresher even in their expert fields.
• Leverage Strong Tools.
• Don’t Get Caught Up on Templates.
• Include Visuals.
• Set a Time for Writing.
• Have a Purpose.
• Keep It Simple.

What are the requirements for documentation and record keeping?

Principles of Good Record Keeping

• Be factual, consistent and accurate;
• Be updated as soon as possible after any recordable event;
• Provide current information on the care and condition of the patient;
• Be documented clearly in such a way that the text cannot be erased;

What is considered false documentation?

False documentation is the process of creating documents which record fictitious events. The documents can then be used to “prove” that the fictional events happened.