ED Legal Letter – February 1, 2006
February 1, 2006
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ED nursing documentation: Read, react, and reconcile
Ever present in the health care provider's training and practice is the continual responsibility to provide documentation. Although it is ever drummed into our heads that proper documentation is necessary for the purposes of billing, quality assurance, and risk management, documentation is also important in real time for the purposes of communication among caregivers. Not only must each health care practitioner record his/her own activities and findings related to a patient's care, but each practitioner also must take heed of every other provider's documentation.