2019 - Best Practices in Nursing Documentation: Writing Effective and Legal Proof Notes

Aspects of E.H.R and how it impacts documentation in positive and negative fashions
Time sequence of documentation ; it’s importance and how to enter related information after the event
Late entries ; why they happen and how to manage them
Signatures what their significance is and why a signature page or record is required to support your electronic signature
Co-signatures ; importance of correct use , how to modify an entry when co-signing documentation
Fact’s versus opinions; the significance of accuracy of reporting without interpretation of events
Need for response documentation ; what happened because of the treatment /action provided
Communication with MD’s /Families and other groups ; why it is essential to include in the medical record