Risk Management Nursing Documentation
Oscar Chavez
NUR 492
May 4, 2012
Susan Dean, RN, MSN, FNP

Risk Management Nursing Documentation

The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk management. In this era of unprecedented change in healthcare, ECRMC has determined it was time to reengineer our existing approach to risk management consulting services to address more current needs for our patients and staff.
The primary technique utilized in overcoming these limitations is to view training not as a stand-alone solution, rather as one element of a full performance improvement plan to address specific areas of concern. Instead of providing a general program on documentation, risk management has been working with nursing departments and other professionals to focus on the areas of deficiency or situations that need improvement. The foundation of risk management was broken into four separate issues. One was to pinpoint the exact nature of the medical record deficiency. Second was to develop criteria and expectations to improve documentation. Third, the current deficiencies were described as well as expectations for improvement via training and other sources to staff. Finally, a method was developed for measuring progress.
Risk management has taken the following pattern. Risk management nurse meets with the floor