nursing documentation

Documentation facilitates communication among providers, ensures continuity of care, & serves as a mechanism for billing/reimbursement (among other things that aren't crossing my mind right now).

Documentation facilitates communication among providers, ensures continuity of care, & serves as a mechanism for billing/reimbursement (among other things that aren't crossing my mind right now).

..........and most importantly.......covers your ass if you ever get taken to court. There are very few things we chart on (besides maybe meds and what not) that are ever really looked at by anyone else but us, but in the event something went wrong with a patient and you're sitting in court watching a prosecutor drag out everything you've been charting, you'll probably be glad if you're a thorough and accurate charter. Otherwise things like shift assessments and safety checks and all are probably rarely ever looked at until something goes wrong.

So much of our job now, especially charting, is all for litigious reasons and has little to do directly with patient care.

Seven words: "If it isn't documented, it didn't happen."

Does it take a while? At first. But as you learn the charting habits and programs of your facility, you become faster. When I started at my current position, it would take me a good ten minutes to chart my initial assessment. Now I'm down to three or four, simply because I know where everything is on the computer.