So I asked one of my students the other day, what is the purpose of the medical records. He replied, “To save us from the attorneys?”. Although joking (I think), this is often the case. So, it begs the question, what should we document and why? Well, first, we have to remember the medical record is the tool for communication among all the health care providers. So, then it becomes obvious, you need to document what everyone should know about the patient and the care that was provided….and be truthful. Simple enough.
Locally we had a verdict of a death of an inmate to the amount of $975 million dollars. Sadly, the inmate was suppose to be monitored by the staff, including the nursing staff. Sure, it was documented she was monitored, however the video told a different story. A few good lessons learned from documentation…. tell the truth and serve the patient. The article goes into great detail of the events and worth the read.
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