Title Improving nursing documentation and reducing risk / Patricia A. Duclos-Miller, MSN, RN, NE-BC

Published Brentwood, Tenn.: Hcpro, a division of BLR, [2016] ©2016

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Description 1 online resource Contents Contemporary nursing practice includes good documentation -- Contemporary nursing standards-why it's important for nurses to document well -- Reducing professional risk through documentation -- Barriers to good nursing documentation -- Improving nursing documentation in this electronic age -- Electronic medical record-advantages and challenges to good nursing documentation -- Ways to engage and motivate staff -- Improving documentation and outcomes through auditing Summary Annotation In the age of electronic health records (EHR) and value-based purchasing, accurate and complete nursing documentation is crucial. Proper documentation affects not only quality of care, but also facilities' costs and revenues. Redundant documentation wastes time and money, while inadequate documentation negatively affects Joint Commission core measures and can result in license suspensions or legal action against a healthcare facility-an expensive and often damaging outcome. Improving Nursing Documentation and Reducing Risk helps nurse managers create policies, processes, and ongoing auditing practices to ensure that complete and accurate documentation is implemented by their staff, without creating additional time burdens. Nurse managers, especially new nurse managers, do not clearly understand their legal accountability for poor or inadequate documentation created by nursing staff who report to them. While each state's nurse practice act (NPA) differs, every NPA addresses nursing liability for documentation; however, many nurse managers remain unaware of these and other regulations that hold them accountable for the documentation crafted by their nurses. This book helps nurse managers protect themselves and their staff by clearly explaining to their employees the impact of documentation practices on reimbursement, educating them on the consequences of failure to document, and training them on how to document properly. This book will help you: Work directly with your staff to ensure accurate documentation Train nurses during orientation Educate your staff on the consequences of inaccurate documentation Create steps to share with your staff that will improve documentation Ensure complete comprehension of documentation issues through sample forms, auditing tools, and case studies Bibliography Includes bibliographical references Subject Nursing -- Documentation HEALTH & FITNESS / Holism HEALTH & FITNESS / Reference MEDICAL / Alternative Medicine MEDICAL / Atlases MEDICAL / Essays MEDICAL / Family & General Practice MEDICAL / Holistic Medicine MEDICAL / Osteopathy Nursing -- Documentation Form Electronic book ISBN 9781683080695 1683080696 1683080688 9781683080688

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