How many times have you heard, "If it's not charted, it didn't happen?" Since our earliest days as student nurses we have been told by instructors and later by nursing supervisors, our facility's risk management departments, and attorneys that documentation in the medical/health record is criticial. It is necessary for both good patient care and liability reduction.

Nursing documentation has come under greater scrutiny as more groups use these records for reimbursement, malpractice evidence, quality assurance, professional review audits and nursing research. Would your documentation withstand scrutiny?

© 2006 NYSNA, all rights reserved.

Course Objectives

Upon completion of this course, the learner will be able to:

• Discuss the purpose of documentation in the patient record.

• Describe factors that impact on documentation.

• Identify regulatory agencies that determine documentation requirements.

• Apply the American Nurses Association's Principles of Documentation.

• Discuss the "who, what, when, where, why, and how" of nursing documentation.