Q What is the best way to document to prevent lawsuits?

A Documentation is the single most important tool in a nurse’s arsenal to avoid a malpractice lawsuit. Complete and comprehensive documentation should first be done in the patient record. The patient’s chart contains all the care and service that has been provided, and it is the first line of review when a patient has alleged an injury. Nursing notes must answer the questions of who, when, where, and why. Charting should include narratives along with flow charts; one without the other gives an incomplete picture of the patient. Because memories dim and recallling a specific situation is difficult, documentation is the best way to refresh your recollection. Documentation is the strongest evidence of whether the patient received appropriate care.

Lack of documentation makes it difficult to support that a procedure was done or a conversation took place in regards...

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