I am trying to find some good websites for me to use in reference to the do's and don'ts in documentation and charting. I need something that says everything on what I need to include in my nurse's notes, etc. Believe it or not NONE of my textbooks have ANYTHING about charting except who, what, where, how and why.
Soemthing that gives examples (sample entries) on what to write would be good. Am planning on purchasing a book about this, but it is not possible right now since I will be paying a lot of car repairs plus my tuition and every dollar counts right now for the next 3 months.
Jul 26, '03
Here are some good articles:
Charting by Exception:
Can You Make Documentation Easier For Me?
More sites w legal focus to keep you out of hot water:
How Poor Documentation Does Damage in the Courtroom
by Sharon Schott, RN
Purposes Documentation Effective Documentation Ethical and Legal ...
LEGAL DOCUMENTATION STANDARDS
Last edit by NRSKarenRN on Jul 26, '03