Improving Nursing Documentation and Reducing Risk
Patricia A. Duclos-Miller, MSN, RN, NE-BC
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.
Nurse managers, especially new nurse managers, do not clearly understand their legal accountability for poor or inadequate documentation created by nursing staff who report to them. While each state’s nurse practice act (NPA) differs, every NPA addresses nursing liability for documentation; however, many nurse managers remain unaware of these and other regulations that hold them accountable for the documentation crafted by their nurses.
This book helps nurse managers protect themselves and their staff by clearly explaining to their employees the impact of documentation practices on reimbursement, educating them on the consequences of failure to document, and training them on how to document properly.
This book will help you:
- Work directly with your staff to ensure accurate documentation
- Train nurses during orientation
- Educate your staff on the consequences of inaccurate documentation
- Create steps to share with your staff that will improve documentation
- Ensure complete comprehension of documentation issues through sample forms, auditing tools, and case studies
Table of Contents
Chapter 1: Contemporary Nursing Practice Includes Good Documentation
Chapter 2: Contemporary Nursing Standards: Why it’s Important for Nurses to Document Well
Chapter 3: Reducing Professional Risk Through Documentation
Chapter 4: Barriers to Good Nursing Documentation
Chapter 5: Improving Nursing Documentation
Chapter 6: Electronic Medical Records: Advantages and Challenges to Good Nursing Documentation
Chapter 7: Ways to Engage and Motivate Staff to Document Well
Chapter 8: Improving Documentation and Outcomes
Meet the Author
Patricia A. Duclos-Miller, MSN, RN, NE-BC, is a professor at Capital Community College in Hartford, Connecticut, in the division of nursing. She continues to advance the professional practice of nursing in her role as a professional development coordinator for Bristol (Connecticut) Hospital, where she has also served as a quality consultant. Duclos-Miller graduated from Saint Anselm College in Manchester, New Hampshire, with a Bachelor of Science in nursing and completed her Master of Science degree at Boston University. She is board certified by the American Nurses Credentialing Center in nursing administration.
Her professional experience includes nursing administration in quality improvement, parent-child health, home health care, and long-term care nursing; practicing as a staff nurse in the specialties of medical-surgical nursing, obstetrical nursing, and neonatal intensive care; and serving as a nursing educator. She is a national speaker on contemporary topics involving nurses in the new-graduate transition and in the development of leadership skills, quality improvement, team building, and documentation.
She is the author of the first and second editions of Managing Documentation Risk: A Guide for Nurse Managers and its accompanying handbook Nursing Documentation: Reduce Your Risk of Liability; Stressed Out About Your First Year of Nursing; and Home Health Documentation Proven Strategies for Clinicians. She has also been a contributor to Strategies for Nurse Managers.
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Published: June 2016