Nursing Documentation: Legal Ramifications My experience as a clinical bedside nurse and a legal nurse consultant has proven to me that many nurses simply do not understand the medical and legal ramifications of poor, incomplete documentation. Yes, the medical record is a document that, if not properly utilized, can lead to problems for the healthcare […]
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The quality of nursing documentation is an important issue for both patients and nurses. Obviously quality nursing documentation enhances patient care as this leads to better communication of the issues. “No matter how skilled or experienced you are, inaccurate or incomplete nursing documentation can mean serious trouble for your patients—and for you if you’re ever […]