Nurse documentation: not done or worse, done the wrong way--Part I.
OBJECTIVE
To focus on nursing documentation and expanding technologies (e.g., facsimile, telephone, e-mail, computer charting) that offer different ways to record, deliver, and receive patient records and avoid nursing liability for inadequate or inaccurate documentation.


METHODS
Nursing, non-nursing healthcare, legal journals, case law, and related Internet sources.


RESULTS
To avoid liability for inadequate or inaccurate documentation, nurses must be aware of the major issues involved in documentation litigation. New technology is altering how healthcare documentation is done and raising new confidentiality issues.


CONCLUSIONS
Nurses should follow their facility's guidelines and principles for documentation of patient care, especially when using more advanced technologies.


CONCLUSIONS
Educating nurses about the principles of documentation and the importance of implementing risk-reduction practices will help guard against liability and ultimately improve patient care.
Frank-Stromborg
M
M
School of Nursing, Northern Illinois University, DeKalb, USA.
Christensen
A
A
Elmhurst
D
D
D004282:Documentation / Q000592:standards*; D006801:Humans; D020407:Internet; D016365:Liability, Legal; D016347:Medical Records Systems, Computerized; D009737:Nursing Records / Q000592:standards*; D011787:Quality of Health Care / Q000331:legislation & jurisprudence; D012984:Software; D016636:Telefacsimile; D013689:Telephone; D014481:United States