An RN’s careful note-taking protects hospital from liability. This month we look at a case in which a nurse’s careful documentation of a patient’s neurologic examination findings saved the day for a ...

Christy Bieber has a JD from UCLA School of Law and began her career as a college instructor and textbook author. She has been writing full time for over a decade with a focus on making financial and ...

Maintaining high quality clinical documentation is essential for a number of reasons, including improved patient safety and better adherence to accreditation standards. Marie Boyd, administrator at ...

The Maryland Board of Nursing said it has cleared almost all of the 259 nurses and nursing applicants who may have obtained a Maryland license using fraudulent documents from a scheme revealed in ...

Across healthcare, efforts to advance documentation are often focused on enhancing physicians’ workflow. But at Baltimore-based Johns Hopkins Hospital, leaders are equally focused on improving ...

Here are 5 goals to consider when writing your notes: 1. Describe behavior or write down statements made by patients or family members, rather than characterizing the behavior or statement. For ...

Is it just me, or is nursing documentation lacking something? I mean, I don’t expect a nurse to write a book, but I don’t want to play Sherlock Holmes when I am trying to read a nurse’s notes, either.

During the trial, Ms L testified on her care of Jane, and her detailed notes were introduced into evidence, including her notes about the 2 neurologic examinations she performed. Drs S and G both ...