Documentation and Regulatory Compliance

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DOCUMENTATION AND REGULATORY COMPLIANCE 3

The disadvantages of charting by exception include the appearance ofgaps that could be interpreted as time spent without checking on thepatient. When there are no observations, notes are not included inthe record, thus there is no proof that the nurse has been attentive.The advantage is that the use of quick symbols while charting can beused in defense as it closes time gaps that may be apparent incharting by exception.

Mistakes are corrected through drawing of a single line over thewrong entry. It is never recommended to use correction fluid or toscribble out wrong entries. It is recommended to employ addendumswhen significant information is not corrected followed by a date,time and signing of the addendum (Westrick &amp Dempski, 2009p.154). The format for documentation when witnessing an adversepatient occurrence starts with the date the adverse event occurred,treatment, grade of the event, attribution and date of resolution(Nickitas, 2014 p.146).

Examples of APOs that have to be reported include a patient’sdeteriorating of conditions that were present during the start oftheir treatment, concurrent diseases and negative reactions tomedication. Medications in this case include concomitant drugs orimmuno-suppressants.

In the court of law charting corrections may result in negativeaftermaths for the physicians. Even when the corrections arelegitimate, properly-intended corrections they are treated assuspicion of illegal intention (O’Farrell, 2010 p.2). It isexpected that the medical record provides a precise outlook of whathappened during a physician’s interaction with the patient.Corrections must be made in the appropriate and recommended method orthey are otherwise considered as a malpractice (O’Farrell, 2010p.2).

When handling forensic issues, nurses must carefully evaluate allcases patients report as accidents. The objective is to rule out anyintentional injury. Forensic issues must be reported prior to anypatient intervention (Lynch, 2011).

References

Lynch, V. A. (2011). Forensic nursing science: Global strategies inhealth and justice. Journal of Forensic Sciences, 1(2),69-76.

Nickitas, D. M. (2014). Policy and politics for nurses and otherhealth professionals. Sudbury: Jones and Bartlett Publishers.

O’Farrell, J. (2010). Medical records: Best friend or worst enemy?Risk Review, 1-2.

Westrick, S. J., &amp Dempski, K.(2009).&nbspEssentialsof nursing law and ethics.Sudbury, Mass: Jonesand Bartlett Publishers.

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