the
and
of
to
you
a
for
You
documentation
care
• Archive: “If you don’t write that, you could lose your license,” or “If you write that, you could lose your license.” This was something I heard during my entire nursing career and I never really knew what it meant.
• I was the nurse who was called into the office to explain an entry, clarify a comment, or “fix” something that had already been noted.
• My thought was, “if you just tell me what I’m supposed to chart, I’ll do it.”In addition to supervisor or facility expectations, there are requirements now in place for electronic charting by the Center for Medicare and Medicaid Services (CMS). In addition, healthcare is highly regulated and full of reimbursement woes, which often are connected with the documentation. What’s a nurse to do…?
• Rosale Lobo, PhD(c), MSN, RN, CNS, LNCC, has the answers!Learn the meaning of being a non-fiction story teller - nurses have been voted the most trusted professionals for years because we are truth tellers.
• We are educated to care for our patients with compassion and ethics, so why has it become difficult to chart according to our personal belief system.