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Discussion

Documentation Resources?

Does anyone have any helpful resources or books on documentation? I attended this workshop and we talked about litigation and it just freaks me out! Sometimes I really think we should have had a whole class in school on documentation becuase its so important. Sometimes I don't know the right way to word something or how to document, help!!!

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I wish there was too. Im a home health care nurse now, and I write like I'm writting a book. each nurse takes their nurses notes home, so I dont get to see what other nurses write. My RN supervisor told me the new nurse has perfect nurses notes. I really wanted to see them, but was afraid to ask. Ive seached to computer and did one CEU on documentation, that told me nothing about how to write them. A book on examples would be a number 1 seller for nurses. Wouldnt it be nice? How about how to chart for each specialty:))))))))))))

I'm sure that somewhere out there you can find a book on charting. Everyone charts differently. As you gain more experience you will find what you feel comfortable charting on and how you want to do it. In the beginning, I tell everyone to chart everything. As you get into various situations, you will see what things you can drop off to save time. But charting IS everything. It can save your butt when nothing else can. Remember the old adage "If it isn't documented it wasn't done"? Attorneys go by this rule. And depositions suck. If it hadn't been for my charting, they could have tried to put my butt in a sling along with the doc that screwed up.

This is one of the primary reasons we have to take a composition class.

I just listed these on another thread

Chart Smart, The A-Z Guide for Better Documentation

Charting Made Incredibly Easy

Complete Guide to Documentation

I too have been laughed at for "charting books" on more than one occasion, but guess what! It saved my butt.

Risk Mgt even said it saved a couple of lawsuites because of the detailed information I had charted.

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For the HH example, lin263, the nurses are supposed to be leaving the field chart copy of their notes in the home so following nurses can refer to them. I even worked for an agency that did not have multiple copy notes, everything was written on a single card for the day, and these were left in the home chart until they were sent to the office at the end of each work week. However, I did come across one nurse who never left her notes, and I saw one of the possible reasons why: she wasn't doing them, until the last minute, all at once.

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