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Documentation Basics and Best Practices

By Jane Belt, MS, RN, RAC-MT, RAC-MTA, QCP - July 23, 2019

A persistent challenge confronts the hard-working staff in nursing homes. How can we take care of our residents when we have so much paperwork? We all have been there: whether electronic or hardcopy, finding the time to document seems to be the last thing we pack into our busy agendas. Considering those busy schedules, we all can use a gentle reminder of just how important every piece of documentation really is. Nurses do not relish the task, but documentation can make the difference between saving or sacrificing you and your license. Moreover, quality documentation can provide a positive impact on resident outcomes. In future articles, we will explore the keys for successful skilled documentation and the records needed to battle any sort of denial scenario. The purpose of this article is to examine the fundamental role charting plays in effective long-term care.

 

Why is documentation so important to every nurse’s job? Let’s review the basics.