June 28, 2017 | | Comments 0
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Nurse managers and the importance of documentation

As a nurse manager (also known as unit leader), regardless of clinical setting, it is your responsibility to assist staff in adhering to both clinical and documentation standards. It is also your responsibility to provide continuing education, ongoing feedback, and input into policy and documentation changes. It is to your advantage to fulfill these responsibilities, because if your staff is involved in a malpractice case, then your ability to manage and meet the quality and risk management standards will be called into question. You may be asked if the staff were following the standards of care based on organizational as well as accreditation or regulatory standards.

As a member of the leadership/management team, you must demonstrate that you have a commitment to providing safe quality patient care. It is your responsibility to ensure that nursing staff comply with up-to-date standards and organizational protocols/policies. The proof for this will be in the medical record. Your role is to support an efficient and effective documentation system and create an expectation that the documentation standards will be followed.

Demonstrate support for this by:

  • Developing or revising an efficient system that meets the requirements of regulatory standards.
  • Analyzing whether the documentation system allows for documentation of critical thinking and the nursing process.
  • Involving the end users in the development or analysis of the system.
  • Emphasizing the importance of documentation through written guidelines, policies, and performance evaluations.

Source: Improving Nursing Documentation and Reducing Risk

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Filed Under: Nursing documentation

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About the Author: Kenneth Michek is the Associate Editor for nurse management at HCPro.

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