article thumbnail

Protect Yourself With These Tips on Proper Documentation

Nurse.com

An RN claims his nurse manager criticized him for documenting in the medical record that a patient was “combative and noncompliant,” after the patient struck the RN and another nurse during discharge. The RN wonders how he should’ve documented the incident since the nurse manager didn’t provide constructive feedback.

article thumbnail

Do’s and don’ts of defensive documentation

American Nurse

DOCUMENTING CARE is a basic nursing responsibility, but it’s one that nurses often struggle with because of time constraints and challenges associated with electronic health records (EHRs), such as poor user interfaces that leave nurses unclear as to where to document findings. The NSO/CNA Nurse Liability Claim Report (4th Ed.)

Insiders

Sign Up for our Newsletter

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

article thumbnail

The Importance of Communication in Home Healthcare

Celayix

It’s fair to say that good communication skills are essential to most jobs. In home healthcare, prioritizing communication is crucial and should receive appropriate attention. Communication is so important in home healthcare as it ensures quality of care, and improves client experience.

article thumbnail

Optimizing Revenue Cycle Management and Clinical Documentation Integrity To Avoid Coding Disasters

Relias

Coding and clinical documentation have never been more important in healthcare. “We You’ll need ongoing training for your staff to improve your clinical documentation and avoid the following coding disasters. The documentation and coding are appropriate on our end. Insufficient Clinical Documentation or Underreported codes.

article thumbnail

National Patient Safety Goals Depend on Good Communication

Relias

Improve staff communication. Perhaps not surprisingly, they share a common element — they all depend on good communication practices at the organizational, team, and individual levels. Whether communicating with care team members or directly with patients, using two ways to confirm a patient’s identity must be embedded in your process.

article thumbnail

Business Planning: Not Just For Startups

Nurse Practitioners in Business

But not all business plans are created equal… And depending on the size and the needs of the business or practice, some may benefit from a traditional, formal business plan, whereas others may do fine with a more informal document. Communication: a business plan is a tool for better communication.

Business 367
article thumbnail

Let’s huddle up

American Nurse

A comprehensive ambulatory cancer center’s journey to implementing tiered huddles Takeaways: Tiered huddles are brief conversations that occur throughout levels of an organization or across health systems to improve patient safety, communication, situational awareness, care coordination, resource utilization, patient outcomes, and service.