Ethical and Legal Documentation Standpoint
Documentation is a written or electronic recording of patient information that forms the patient’s medical record. Per Jensen, “the patient clinical record contains recorded information from all health care encounters” (Jensen, 2011, p. 69). Within nursing, documentation,” should communicate observations, decisions, actions and outcomes related to patient issues and care” (Blair & Smith, 2012, para. 6).There are ethical and legal ramifications regarding this record, both positive and negative. Nurses need to be aware of how this record can affect them and what their responsibilities are considering this.
The most important legal and ethical consideration, according to Mayer and Meyer, legal nurse …show more content…
An additional pro resultant from clear and accurate documentation is that the ” one common thread in all the medical malpractice cases I’ve studied, we would have to say the single most important way to protect yourself as a nurse lies in your documentation”(Mayer & Mayer, 2011, p. 20). If you document the exceptional care that you provide in a way that is understandable to the general public, that documentation can in the end protect you and your licensure during legal proceedings and board reviews (Mayer & Mayer, 2011). A third positive of high-quality documentation is the fostering of quality improvement with its use,” the chart provides a means for risk management and performance improvement committees to evaluate the quality” of nursing care provided (Sullivan, 2004, para. 1). “The medical record is also used by third-party payers for reimbursement purposes and by administrative agencies for accreditation or licensing review” (Sullivan, 2004, para. 1) is a fourth affirmative point in regard to documentation. We are all familiar with the dreaded state, Medicare and JCAHO reviews; it is often strong and precise documentation that provides us with a positive outcome from these