Avoid Malpractice Lawsuit By Upholding Appropriate Nursing Documentation

In nursing practice, there should be no room for errors. Everything must be well accounted for and documented in order to provide the necessary treatment and care for patients. If nursing documentation isn’t done the right way, the nurse can be in real trouble. All the nurses are well aware of the standard for nursing practice, which require every one of them to document appropriate and accurate reports of significant observations including conclusions obtained from those observations.

A truthful and precise nursing documentation can help nurses defend themselves in the case of malpractice lawsuit, not to mention keeping them of court or possible imprisonment. There will never be any lawsuit due to malpractice if only proper nursing documentation is being followed. Besides, it is not something that nurses learn only during the first day of their job. They were trained to do it while they were still studying. They will never become nurses in the first place had they not learned how to chart everything affecting patient’s care, will they?

In nursing documentation, there are certain things that nurses can do and cannot do in order for them to avoid mistakes. Again, there’s no room for mistakes when it comes to nursing practice. Let us first take a look at the things nurses can do. Before doing any nursing documentation, make sure you have the right chart. It may sound very basic, but it is important, in case there’s an error, the investigation starts here. Also, make your writing readable, because you won’t be the only one to read the documentation.

Make sure that your documentation reflects the nursing process and your professional skills. The times when you give medications, the administration route, and the patients’ responses should be correctly charted. Any precautions or preventive measure used must be recorded, as well as phone calls to a physician with exact time message and response. If there’s an important point you remember after the completion of nursing documentation, record the information with a note that it’s a late entry.

Now, let’s go to the things nurses cannot do. In a nursing documentation, bear in mind that you cannot change or modify any patient’s record as it is a criminal offense, but of course nurses knew this already. You cannot document what other people said or observed, unless the information is serious and important. You cannot and should not document care ahead of time as something may happen and you may not be able to five the care you have documented beforehand. Besides, charting care that wasn’t done is fraud, so think about it!

Be specific on your descriptions, you cannot just describe something vaguely, like large amount or bed soaked. In order to uphold accurate nursing documentation, you cannot use abbreviations, or shorthand that are not widely accepted or better yet, don’t use them at all. That way, you can provide nursing documentation that is legible for anyone to read.

As you may have noticed, nursing documentation is a serious procedure that should be done the right way without any errors at all. The reminder is worth repeating, considering what you may end up with in case something goes wrong in you documentation. So, be very careful!

Public Health Nursing

Isn’t it good health one of our priorities in the family among other things? With that in mind, wouldn’t it be very comforting to know also if the community where we live in also promotes public health nursing? Even if your eyebrows meet and your forehead carries a large question mark because you don’t know exactly it means and what it can do to your community, but if you read it between the lines, I’m sure you would say yes right away!

But, what really is public health nursing? For some, the words may sound familiar, while others may find the words confusing. Actually, public health nursing is the practice of upholding and protecting the health of the community by using the knowledge learned from nursing, social, and public health sciences. Given the good intention of public health nursing, it is not surprising to know that you can find public health nursing almost anywhere in the country.

Public health nursing is, in fact, developed to describe its specific roles and to provide a guide for public health nursing practice in the ever growing health care system. However, the public health nursing practice can be affected by certain factors, such as environmental, biological, cultural, economic, social and political aspects of a community. Due to the fact that public health nursing is an integral part of the healthcare system, the former is also responsive to these factors by way of working with the community in promoting health and preventing disease, injury and disability.

As public health nurses, their role is to integrate community health involvement and knowledge about the entire community with personal and clinical understandings of the health and illness experiences of individuals and families within the community. Also, they interpret and express the health and illness experiences of different, usually vulnerable individuals and families in the community to health planners and policy makers and assist members of the community to speak up their problems and hopes.

A public health nursing may be carried out even by only one public health nurse or by a group of public health nurses working together for the same purpose. There could be many activities that public health nurses can do in order to promote good health and protect the health of the entire community. One of the best examples is providing health education, care management and primary care to the people and families, especially those who are members of vulnerable community.

Our world could be a better place to live in if only all the community encourage public health nursing in order to have disease-free and health-conscious family. And since family is the smallest unit of a community, the awareness in promoting health should start within it. This is much easier to achieve through the help of public health nurses, knowing that it only takes one public health nurse to operate a public health nursing.