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If It’s Not Documented, It Was Not Done

Empowered Nurses

How many times have you heard this “If it’s not documented, it was not done?” Your documentation will save you every time. Some common areas where lack of documentation becomes concerning include: Failing to document Verbal Orders. It is imperative to document verbal orders. I assume many and it is so true.

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Simplifying Medical Documentation: The Role of Healthcare Document Scanners

Scrubs

Amidst this chaos enters a hero—the healthcare document scanner , a tool that is fast becoming as essential to healthcare practices as stethoscopes and scrubs. Let’s delve into the heart of how this technology is reshaping the landscape of healthcare documentation. However, taking the leap isn’t as daunting as it appears.

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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.)

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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.

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Documentation and Provider Standards Training

American Medical Compliance

The following Documentation and Provider Standards Training educates healthcare providers on the significance of documentation compliance in healthcare. Documentation Guidelines and Standards The legal system views documentation as a fundamental component.

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How digital health documentation transforms professional practices in primary healthcare in Denmark: A WPR document analysis

Nursing Inquiry

Today, this mandatory task increasingly takes place as digital documentation. This study critically examines problem constructions in practical documents on digital documentation strategies in Danish municipal healthcare and how these problem constructions imply particular solutions. was applied.

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Can Nurses Document Medical Diagnoses in Patients’ Charts?

Nurse.com

A physician signs off on patients’ visits and completes the documentation in the electronic medical records (EMR). Medical diagnosis vs. nursing diagnosis The existing documentation practices are bothersome for several reasons. First, are her decisions and documentation considered a medical diagnosis?