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Improving Nursing Documentation and Reducing Risk

In the age of electronic health records (EHR) and value-based purchasing, accurate and complete nursing documentation is crucial. Proper documentation affects not only quality of care, but also facilities’ costs and revenues. Redundant documentation wastes time and money, while inadequate documentation negatively affects Joint Commission core measures and can result in license suspensions or legal action against a healthcare facility—an expensive and often damaging outcome.

Improving Nursing Documentation and Reducing Risk helps nurse managers create policies, processes, and ongoing auditing practices to ensure that complete and accurate documentation is implemented by their staff, without creating additional time burdens.

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This book will help you:

Work directly with your staff to ensure accurate documentation
Train nurses during orientation
Create steps to share with your staff that will improve documentation
Educate your staff on the consequences of inaccurate documentation
Ensure complete comprehension of documentation issues through sample forms, auditing tools, and case studies

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MAGNET(TM), MAGNET RECOGNITION PROGRAM(R), and ANCC MAGNET RECOGNITION(R) are trademarks of the American Nurses Credentialing Center (ANCC). The products and services of HCPro are neither sponsored nor endorsed by the ANCC. The acronym "MRP" is not a trademark of HCPro or its parent company. HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks, the Accreditation Council for Graduate Medical Education, which owns the ACGME trademark, or the Accreditation Association for Ambulatory Health Care (AAAHC). HCPro is not affiliated in any way with the Institute for Healthcare Improvement (IHI).