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Booklets

72 (PLUS) Tips for Accurate, Legal and Ethical Documentation

Do you find yourself putting off charting and staying late to complete it? Or have you been told that your documentation needs some serious attention? If this sounds familiar, there is wonderful tool to get you up to speed, 72 (PLUS) Tips for Accurate, Legal and Ethical Documentation.

Here's some of the many benefits of using 72 (PLUS) Tips for Accurate, Legal and Ethical Documentation:

  1. Learn the basics of documentation, such as the meaning of your signature and how to protect its validity.
  2. Gain a deeper understanding as to why accurate documentation is directly linked to effective continuity of care.
  3. Learn which medical abbreviations to use/not to use when charting.
  4. Understand how to employ your senses (smell, vision, touch, etc.) in your documentation in order to provide a more accurate picture of a patient's condition.
  5. Find out how to consistently keep your documentation legal and ethical, including what to record and what not to record in a chart.
  6. Learn the specific legal and ethical requirements of informed consent.
  7. Become more informed about the Health Insurance Portability and Accountability Act (HIPPA), including a nurse's role in compliance with this law.
  8. Learn more about computerized documentation, including how to avoid making mistakes and protecting patient privacy when charting in public spaces.
  9. Learn unique time saving techniques that will help you stay on top of your charting during your shift.

PLUS: Useful examples accompany most of the tips to enhance your understanding.

Bonus: JCAHO's do not use list is included….a resource you can't do without!

This invaluable tool is offered only as a digital download.