Documentation issues | Applied Sciences homework help

Based on the information you have learned in the course so far and the readings analyze the advantages and disadvantages of charting by exception when faced with a malpractice lawsuit. Discuss how you would correct mistakes in a medical chart and the formatting of your documentation when witnessing an adverse patient occurrence. How would these corrections be perceived in a court of law?

Connect with a professional writer in 5 simple steps

Please provide as many details about your writing struggle as possible

Academic level of your paper

Type of Paper

When is it due?

How many pages is this assigment?

 

 

I need this answer to be very detailed I need at least 3 APA citations wiht peer reviewed as well as 400 plus words…….. THis is an easy topic and I need to see good results I am willing to purchase 2 to compare….. please note the deadline!!!!! 

 

 

 

Advantages and Disadvantages of Charting By Exception

 

Charting by exception can be a risky practice even if it does free up the nurse to provide more care to their patients. This practice does not provide incomplete documents but they are also not as complete as they could be since there is a lack of detail. The majority of the charting occurs when the patient’s condition changes and then the nurse has to be detailed and specific to these changes as well as responses to interventions (Nurses Service Organization, 2013). I was always a fan of charting by exception because I preferred to be at the bedside with my patients. I did; however, make occasional notes pertaining to the patients’ conditions so that there was documentation of how their days were progressing and how they were doing.

 

Correct Mistakes in a Medical Chart

 

In order to prevent errors in the medical records, there are a few things that a nurse should keep in mind (these apply to either written charting, electronic charting, or both):

  • Write legibly
  • Be objective; subjective commentary can get you in trouble
  • Never label the patient or their behavior
  • Document exact times
  • Avoid gaps in the record
  • Follow facility policies/procedures at all times
  • Document adverse events immediately
  • Document all patient teaching
  • Document all medication, teaching, or activities the patient refuses
  • Never erase, scribble out or use write-out for errors – follow the policy for correcting these errors (one line through entry with initials/time/date

 

This is a partial list but I think you get the idea. There are many things you must ensure you do so that your documentation does not leave you vulnerable to trouble.

 

Documentation of Adverse Patient Occurrence

As with any documentation there are some rules to follow in documenting adverse events. There are:

  • State the Facts only: Only information you see, hear, or otherwise collect through your senses; be specific and do not label; use neutral language and avoid bias.
  • Avoid value judgments
  • Be accurate
  • Document completely all the event, times, individuals involved, patient responses, etc.
  • Be timely document as soon as possible and include the times and dates of all events.
  • Do not chart in advance or too late after the event.
  • Be specific about times and events when completing a late entry. (Di Leonardi, 2012).

 

References

Austin, S. (2011, April). Stay out of court with proper documentation. Nursing2014, 41(4), 24-29. Retrieved fromhttp://www.nursingcenter.com/lnc/cearticle?tid=1150680

Di Leonardi, B. C. (2012, June 1). Professional documentation: Safe, effective, and legal. AMN Healthcare Education Services. RN.com.Retrieved from http://www.rn.com/getpdf.php/2062.pdf?Main_Session=7004d8a3cd66957ac9aa36b371c05f1e

 Nurses Service Organization. (2013). Charting by exception: The legal risks. Retrieved from http://www.nso.com/nursing-resources/article/68.jsp

 

Order a unique copy of this paper
(550 words)

Approximate price: $22

Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our Guarantees

At Myrestlab.com, we always work diligently to provide our customers with high-quality nursing assignment help services. We ensure that all papers by our writers possess 100% originality. We also guarantee all students of 100% privacy and confidentiality when working with us.

Money-Back Guarantee

At Myrestlab.com, our mission is to provide quality services to all students. We, therefore, guarantee money-backs for the rare occasions of satisfaction. Your satisfaction is our goal.

Read more

Zero-Plagiarism Guarantee

All our nursing assignment help services are 100% original. Each of our professional writers develops custom papers from scratch to reduce the chances of plagiarism. In addition to this, we always run completed papers through advanced anti-plagiarism checkers for 100% originality.

Read more

Free Revision Policy

Our free revision guarantee is a courtesy service by Myrestlab.com to ensure that we achieve 100% customer satisfaction rates. In case you feel unsatisfied with the outcome of your paper, you can always request for free unlimited revisions. We recommend a revision request within 14 days after the delivery date for short papers and 30 for dissertations.

Read more

Privacy Policy

Myrestlab.com also guarantee 100 privacy and confidentiality. We do not share any of our customers’ personal details with third parties. We have also fitted our websites with security features to ensure secure connections. Our security features also prevent damages that might occur through attacks by outsiders.

Read more

Fair-Cooperation Guarantee

By ordering a paper through My Rest Lab, you agree to receive nursing assignment help services offered by our nursing assignment writers. Our assignment help experts will always endear to provide quality services as promised. We always expect maximum cooperation from our students to help us achieve our mission and vision.

Read more

Calculate the price of your order

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
$26
The price is based on these factors:
Academic level
Number of pages
Urgency